1619972221 NPI number — DR. DENNIS GRAHAM D.O.

Table of content: DR. DENNIS GRAHAM D.O. (NPI 1619972221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619972221 NPI number — DR. DENNIS GRAHAM D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
DENNIS
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

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 Information

NPI Number:
1619972221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
09/27/2005
NPI Reactivation Date:
03/17/2009

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
150 RIVER NORTH BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEPHENVILLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76401-1803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-968-6051
Provider Business Mailing Address Fax Number:
254-968-4204

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 RIVER NORTH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STEPHENVILLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76401-1803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-968-6051
Provider Business Practice Location Address Fax Number:
254-968-4204
Provider Enumeration Date:
06/20/2005

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: 207X00000X , with the licence number:  F6684 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 141204101 . This is a "TEXAS PROVIDER IDENTIFIER" identifier , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8978M0 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 113891100 . This is a "FIRST CARE PROVIDER NUMBE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 200040612 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 206304301 . This is a "UNITED HEALTHCARE PROV NO" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 6300665002 . This is a "CIGNA PROVIDER NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 7182209 . This is a "AETNA PROVIDER NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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