Provider Demographics
NPI:1366559395
Name:KERSHAW CNTY PSYCH LLC
Entity type:Organization
Organization Name:KERSHAW CNTY PSYCH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUDHAKAR
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:MORTHALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-599-7183
Mailing Address - Street 1:2039 WEST DEKALB
Mailing Address - Street 2:BUILDING 1 SUITE 1
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-2092
Mailing Address - Country:US
Mailing Address - Phone:800-599-7183
Mailing Address - Fax:803-788-9564
Practice Address - Street 1:2039 WEST DEKALB
Practice Address - Street 2:BUILDING 1 SUITE 1
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-2092
Practice Address - Country:US
Practice Address - Phone:800-599-7183
Practice Address - Fax:803-788-9564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC284782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC=========OtherFEDERAL TIN