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General NPI Number Information
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NPI Number | 1710215256
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Entity Type | Organization
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Legal Business Name | SOUTHPARK PEDIATRICS, P.A.
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Dates
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Enumeration Date | 11/20/2009
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Last Update Date | 11/20/2009
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Provider Practice Location Address
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Address Line | 4601 PARK RD SUITE 100
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City | CHARLOTTE
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State | NC
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Zip | 28209-3239
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Country | US
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Telephone | 704-522-6656
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Fax | 704-522-6665
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Provider Business Mailing Address
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Address Line | 4601 PARK RD SUITE 100
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City | CHARLOTTE
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State | NC
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Zip | 28209-3239
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Country | US
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Telephone | 704-522-6656
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Fax | 704-522-6665
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | MS. LESLIE C BROWN
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Credential |
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Telephone | 704-896-9830
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 9501464
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License Number State | NC
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