Provider Demographics
NPI:1205137817
Name:RUPA SHETTY LLC
Entity type:Organization
Organization Name:RUPA SHETTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:L
Authorized Official - Last Name:RYBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-461-6133
Mailing Address - Street 1:237 AVENUE OF THE PALMS
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-1247
Mailing Address - Country:US
Mailing Address - Phone:843-461-6133
Mailing Address - Fax:843-234-6100
Practice Address - Street 1:237 AVENUE OF THE PALMS
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-1247
Practice Address - Country:US
Practice Address - Phone:843-461-6133
Practice Address - Fax:843-234-6100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC276042084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3344OtherWACCAMAW CENTER FOR MENTAL HEALTH