Provider Demographics
NPI:1447389051
Name:DPMKISHNRSC LLC
Entity Type:Organization
Organization Name:DPMKISHNRSC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:N
Authorized Official - Last Name:KISH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:803-466-0504
Mailing Address - Street 1:411 LOCKMAN RD
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-8715
Mailing Address - Country:US
Mailing Address - Phone:803-466-0504
Mailing Address - Fax:
Practice Address - Street 1:411 LOCKMAN RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-8715
Practice Address - Country:US
Practice Address - Phone:803-466-0504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC144213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCU56496Medicare UPIN
SC8777Medicare PIN