Provider Demographics
NPI:1669495867
Name:GRAHAM, TONEY JR (MD)
Entity Type:Individual
Prefix:MR
First Name:TONEY
Middle Name:
Last Name:GRAHAM
Suffix:JR
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 1:1278 MOORE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-4601
Mailing Address - Country:US
Mailing Address - Phone:843-389-7251
Mailing Address - Fax:843-389-7253
Practice Address - Street 1:1278 MOORE ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-4601
Practice Address - Country:US
Practice Address - Phone:843-389-7251
Practice Address - Fax:843-389-7253
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC89530261QP2300X
SC08953207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC089530Medicaid
SC089530Medicaid