Provider Demographics
NPI:1063493591
Name:BOULWARE, RALEIGH J (MD)
Entity Type:Individual
Prefix:DR
First Name:RALEIGH
Middle Name:J
Last Name:BOULWARE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2046
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-2046
Mailing Address - Country:US
Mailing Address - Phone:803-461-3000
Mailing Address - Fax:803-461-4914
Practice Address - Street 1:7 MEDICAL PARK
Practice Address - Street 2:SUITE 104
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223
Practice Address - Country:US
Practice Address - Phone:803-434-3400
Practice Address - Fax:803-434-3938
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC85002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC085008Medicaid
SC085008Medicaid