Provider Demographics
NPI:1790710093
Name:GRAHAM, JOHN M JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:2093 HENRY TECKLENBURG DR STE 200E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5742
Practice Address - Country:US
Practice Address - Phone:843-958-2500
Practice Address - Fax:843-958-2680
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12856207RS0010X, 207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC128560Medicaid
SCP00648646OtherRAILROAD MEDICARE ID
SCP00754387OtherRAILROAD MC ID-RSFPN
SCD178015551Medicare PIN
SCD178019223Medicare PIN
SCP00648646OtherRAILROAD MEDICARE ID