1255354403 NPI number — DR. STEPHEN B GRAHAM DO

Table of content: DR. STEPHEN B GRAHAM DO (NPI 1255354403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255354403 NPI number — DR. STEPHEN B GRAHAM DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
STEPHEN
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1255354403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 291943
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37229-1943
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
833-952-0829
Provider Business Mailing Address Fax Number:
615-237-1434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 LAMBERT ST STE 222
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STAUNTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24401-2446
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
833-356-4080
Provider Business Practice Location Address Fax Number:
607-547-6303
Provider Enumeration Date:
07/26/2006

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: 207V00000X , with the licence number:  0102204996 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1007727440008 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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