Provider Demographics
NPI:1013280650
Name:MT. PLEASANT PSYCHIATRY LLC
Entity type:Organization
Organization Name:MT. PLEASANT PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CANNON
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:II
Authorized Official - Credentials:DO
Authorized Official - Phone:843-400-4089
Mailing Address - Street 1:874 WHIPPLE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-8901
Mailing Address - Country:US
Mailing Address - Phone:843-400-4089
Mailing Address - Fax:877-832-2114
Practice Address - Street 1:874 WHIPPLE RD STE 200
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-8901
Practice Address - Country:US
Practice Address - Phone:843-400-4089
Practice Address - Fax:877-832-2114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-13
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC1442.MDO2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC000000556470OtherBLUE CROSS BLUE SHIELD