Provider Demographics
NPI:1336175603
Name:JOHNSON, GRAEME HENRY (MD)
Entity type:Individual
Prefix:DR
First Name:GRAEME
Middle Name:HENRY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MEDICAL PARK RD
Mailing Address - Street 2:SUITE 200 A
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-8003
Mailing Address - Country:US
Mailing Address - Phone:803-434-7950
Mailing Address - Fax:803-434-8606
Practice Address - Street 1:8301 FARROW RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-3245
Practice Address - Country:US
Practice Address - Phone:803-935-5604
Practice Address - Fax:803-935-5380
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC133792080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC133796Medicaid
SCD176332389Medicare PIN
D17633Medicare UPIN