Provider Demographics
NPI:1679596548
Name:ORTHOPAEDIC SPECIALISTS OF CHARLESTON
Entity Type:Organization
Organization Name:ORTHOPAEDIC SPECIALISTS OF CHARLESTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:843-958-2500
Mailing Address - Street 1:2093 HENRY TECKLENBURG DR
Mailing Address - Street 2:STE 200
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-5741
Mailing Address - Country:US
Mailing Address - Phone:843-958-2500
Mailing Address - Fax:843-958-2635
Practice Address - Street 1:2093 HENRY TECKLENBURG DR
Practice Address - Street 2:STE 200
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414
Practice Address - Country:US
Practice Address - Phone:843-958-2500
Practice Address - Fax:843-958-2635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30267207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP1578Medicaid
SCGP1578Medicaid