Provider Demographics
NPI:1295921724
Name:SOUTHLAKE PSYCHIATRY PC
Entity type:Organization
Organization Name:SOUTHLAKE PSYCHIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FITZGERALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-894-9309
Mailing Address - Street 1:903 NORTHEAST DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-7416
Mailing Address - Country:US
Mailing Address - Phone:704-894-9309
Mailing Address - Fax:704-894-9304
Practice Address - Street 1:903 NORTHEAST DR
Practice Address - Street 2:SUITE 301
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036
Practice Address - Country:US
Practice Address - Phone:704-894-9309
Practice Address - Fax:704-894-9304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC93001122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCB3348OtherBCBS
NC8932269Medicaid