1083698146 NPI number — ALVAN LEON GRAHAM JR.

Table of content: ALVAN LEON GRAHAM JR. (NPI 1083698146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083698146 NPI number — ALVAN LEON GRAHAM JR.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
ALVAN
Provider Middle Name:
LEON
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GRAHAM
Provider Other First Name:
LEON
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
JR.
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1083698146
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 156
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRENTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30752-0156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-657-7559
Provider Business Mailing Address Fax Number:
706-657-3937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5377 HIGHWAY 136
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRENTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30752-2900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-657-7559
Provider Business Practice Location Address Fax Number:
706-657-3937
Provider Enumeration Date:
12/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPT000853 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00186293A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009802850 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08821 . This is a "BC BS OF AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 410034780 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 52066170-001 . This is a "BC BS OF GA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 621040320 . This is a "OTHER INSURANCE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 0049158 . This is a "BC BS OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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