Provider Demographics
NPI:1871541789
Name:GRAHAM, CARLA CAMILLE (MD)
Entity type:Individual
Prefix:DR
First Name:CARLA
Middle Name:CAMILLE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 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
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16126174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2827Medicaid
SCG27118Medicare UPIN
SCGP2827Medicaid