Provider Demographics
NPI:1487858163
Name:J-RAPHA CLINIC LLC
Entity Type:Organization
Organization Name:J-RAPHA CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONATUS
Authorized Official - Middle Name:M
Authorized Official - Last Name:EGBONIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-433-7991
Mailing Address - Street 1:1042 PROFESSIONAL COURT
Mailing Address - Street 2:
Mailing Address - City:MANNING
Mailing Address - State:SC
Mailing Address - Zip Code:29102-2827
Mailing Address - Country:US
Mailing Address - Phone:803-433-7991
Mailing Address - Fax:803-433-7791
Practice Address - Street 1:1042 PROFESSIONAL COURT
Practice Address - Street 2:
Practice Address - City:MANNING
Practice Address - State:SC
Practice Address - Zip Code:29102-2827
Practice Address - Country:US
Practice Address - Phone:803-433-7991
Practice Address - Fax:803-433-7791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20233207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00423235OtherRAILROAD MEDICARE
SC0116367OtherGHI
SC20049632OtherSELECT HEALTH FIRST CHOICE
SC202337Medicaid
SC202337Medicaid
SC8796Medicare UPIN
SCG79208Medicare UPIN