Healthcare Provider Details

I. General information

NPI: 1336175603
Provider Name (Legal Business Name): GRAEME HENRY JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 12/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8301 FARROW RD
COLUMBIA SC
29203-3245
US

IV. Provider business mailing address

9 MEDICAL PARK RD SUITE 200 A
COLUMBIA SC
29203-8003
US

V. Phone/Fax

Practice location:
  • Phone: 803-935-5604
  • Fax: 803-935-5380
Mailing address:
  • Phone: 803-434-7950
  • Fax: 803-434-8606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number13379
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: