1558547430 NPI number — MRS. ELIZABETH WHITE GRAHAM RPH

Table of content: MRS. ELIZABETH WHITE GRAHAM RPH (NPI 1558547430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558547430 NPI number — MRS. ELIZABETH WHITE GRAHAM RPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
ELIZABETH
Provider Middle Name:
WHITE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RPH
Provider Gender Code:
F

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:
1558547430
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5300 WEST GENESEE STREET
Provider Second Line Business Mailing Address:
PO BOX 128
Provider Business Mailing Address City Name:
CAMILLUS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13031
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-487-0435
Provider Business Mailing Address Fax Number:
315-487-0332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5300 W GENESSE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMILLUS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13031-0128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-487-0435
Provider Business Practice Location Address Fax Number:
315-487-0332
Provider Enumeration Date:
01/10/2008

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: 183500000X , with the licence number:  043124 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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