{
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"IsOrgSubpart": "N",
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"OrgName": "SOUTHPARK PEDIATRICS, P.A.",
"LastName": null,
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"FirstLineMailingAddress": "4601 PARK RD",
"SecondLineMailingAddress": "SUITE 100",
"MailingAddressCityName": "CHARLOTTE",
"MailingAddressStateName": "NC",
"MailingAddressPostalCode": "28209-3239",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "704-522-6656",
"MailingAddressFaxNumber": "704-522-6665",
"FirstLinePracticeLocationAddress": "4601 PARK RD",
"SecondLinePracticeLocationAddress": "SUITE 100",
"PracticeLocationAddressCityName": "CHARLOTTE",
"PracticeLocationAddressStateName": "NC",
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"PracticeLocationAddressTelephoneNumber": "704-522-6656",
"PracticeLocationAddressFaxNumber": "704-522-6665",
"EnumerationDate": "11/20/2009",
"LastUpdateDate": "11/20/2009",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BROWN",
"AuthorizedOfficialFirstName": "LESLIE",
"AuthorizedOfficialMiddleName": "C",
"AuthorizedOfficialTitle": "PRACTICE ADMINISTRATOR",
"AuthorizedOfficialNamePrefix": "MS.",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "704-896-9830",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "174400000X",
"TaxonomyName": "Specialist",
"LicenseNumber": "9501464",
"LicenseNumberStateCode": "NC",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}