Provider Demographics
NPI:1053629287
Name:GENPSYCH OF SOUTH CAROLINA LLC
Entity Type:Organization
Organization Name:GENPSYCH OF SOUTH CAROLINA LLC
Other - Org Name:GENPSYCH INC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ODUNLAMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-231-0511
Mailing Address - Street 1:2 MEDICAL CT
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4760
Mailing Address - Country:US
Mailing Address - Phone:803-774-4020
Mailing Address - Fax:803-774-4025
Practice Address - Street 1:2 MEDICAL CT
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4760
Practice Address - Country:US
Practice Address - Phone:803-774-4020
Practice Address - Fax:803-774-4025
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GENPSYCH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-22
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA072910002084P0800X
SC210752084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC110BHSMedicaid