Provider Demographics
NPI:1417972548
Name:GRAHAM, JED ALAN (MD)
Entity Type:Individual
Prefix:
First Name:JED
Middle Name:ALAN
Last Name:GRAHAM
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 1:124 YUCCA CT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29649-9422
Mailing Address - Country:US
Mailing Address - Phone:864-993-1984
Mailing Address - Fax:864-532-2527
Practice Address - Street 1:124 YUCCA CT
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29649-9422
Practice Address - Country:US
Practice Address - Phone:864-993-1984
Practice Address - Fax:864-532-2527
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23953207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCL38500Medicaid
SCL38500Medicaid
SC7764Medicare ID - Type Unspecified