Provider Demographics
NPI:1679594261
Name:CAROLINA FACIAL PLASTIC SURGERY PA
Entity Type:Organization
Organization Name:CAROLINA FACIAL PLASTIC SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:CAMILLE
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:843-665-0400
Mailing Address - Street 1:1714 GREGG AVE
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4120
Mailing Address - Country:US
Mailing Address - Phone:843-665-0400
Mailing Address - Fax:843-667-8487
Practice Address - Street 1:1714 GREGG AVE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4120
Practice Address - Country:US
Practice Address - Phone:843-665-0400
Practice Address - Fax:843-667-8487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16126207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2827Medicaid
SC6751Medicare ID - Type Unspecified
G27118Medicare UPIN