1497749477 NPI number — ALECIA ELLEN GRAVES MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497749477 NPI number — ALECIA ELLEN GRAVES MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

GRAVES

Provider First Name:

ALECIA

Provider Middle Name:

ELLEN

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1497749477

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

01/19/2021

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 776351

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CHICAGO

Provider Business Mailing Address State Name:

IL

Provider Business Mailing Address Postal Code:

60677-6351

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

502-588-9490

Provider Business Mailing Address Fax Number:

502-272-5116

Provider First Line Business Practice Location Address:

4123 DUTCHMANS LANE

Provider Second Line Business Practice Location Address:

SUITE 507

Provider Business Practice Location Address City Name:

LOUISVILLE

Provider Business Practice Location Address State Name:

KY

Provider Business Practice Location Address Postal Code:

40207-4730

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

502-423-9595

Provider Business Practice Location Address Fax Number:

502-719-0161

Provider Enumeration Date:

09/07/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207V00000X , with the licence number:  31847 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 000057120P . This is a "HUMANA - WS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 5002880 . This is a "MEDICAID PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 65925109 . This is a "MEDICAID GRP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 8382591 . This is a "CIGNA-WS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 000000724240 . This is a "ANTHEM - WS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 1166219 . This is a "GROUP MEDICAID PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 50034482 . This is a "PASSPORT - WS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 1052052 . This is a "PASSPORT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 127014 . This is a "SIHO - WS" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 5581 . This is a "MEDICARE GRP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
• Identifier: 64318470 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".