Provider Demographics
NPI:1679622013
Name:TARUNENDU S DWIVEDI MD PC
Entity Type:Organization
Organization Name:TARUNENDU S DWIVEDI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TARUNENDU
Authorized Official - Middle Name:SHEKHAR
Authorized Official - Last Name:DWIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-329-7778
Mailing Address - Street 1:1721 EBENEZER RD
Mailing Address - Street 2:SUITE 265
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-4103
Mailing Address - Country:US
Mailing Address - Phone:803-329-7778
Mailing Address - Fax:803-329-7843
Practice Address - Street 1:1721 EBENEZER RD
Practice Address - Street 2:SUITE 265
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-4103
Practice Address - Country:US
Practice Address - Phone:803-329-7778
Practice Address - Fax:803-329-7843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC268612084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC268613Medicaid
SCI40307Medicare UPIN
SC268613Medicaid