Healthcare Provider Details

I. General information

NPI: 1477077329
Provider Name (Legal Business Name): UDERITZ FAMILY PSYCHIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3227 WALTER DR STE 3B
JOHNS ISLAND SC
29455-8171
US

IV. Provider business mailing address

3227 WALTER DR STE 1B
JOHNS ISLAND SC
29455-8171
US

V. Phone/Fax

Practice location:
  • Phone: 843-872-5454
  • Fax: 843-872-5501
Mailing address:
  • Phone: 843-872-5454
  • Fax: 843-872-5501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number34478
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34478
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DANIEL JAY UDERITZ
Title or Position: OWNER - PSYCHIATRIST
Credential: MD
Phone: 843-872-5454