Healthcare Provider Details

I. General information

NPI: 1679622013
Provider Name (Legal Business Name): TARUNENDU S DWIVEDI MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 EBENEZER RD SUITE 265
ROCK HILL SC
29732-4103
US

IV. Provider business mailing address

1721 EBENEZER RD SUITE 265
ROCK HILL SC
29732-4103
US

V. Phone/Fax

Practice location:
  • Phone: 803-329-7778
  • Fax: 803-329-7843
Mailing address:
  • Phone: 803-329-7778
  • Fax: 803-329-7843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number26861
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number26861
License Number StateSC

VIII. Authorized Official

Name: DR. TARUNENDU SHEKHAR DWIVEDI
Title or Position: PRESIDENT
Credential: MD
Phone: 803-329-7778