Provider Demographics
NPI:1043213960
Name:GRAHAM, CHARLES DUDLEY (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DUDLEY
Last Name:GRAHAM
Suffix:
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 1:2910 TRICOM ST
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9350
Mailing Address - Country:US
Mailing Address - Phone:843-572-9211
Mailing Address - Fax:843-572-0457
Practice Address - Street 1:2910 TRICOM ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9350
Practice Address - Country:US
Practice Address - Phone:843-572-9211
Practice Address - Fax:843-572-0457
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11628207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC116289Medicaid
C612826292Medicare ID - Type Unspecified
SC116289Medicaid