1700801313 NPI number — SCOTT ALLAN GRAHAM MD

Table of content: SCOTT ALLAN GRAHAM MD (NPI 1700801313)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700801313 NPI number — SCOTT ALLAN GRAHAM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAHAM
Provider First Name:
SCOTT
Provider Middle Name:
ALLAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1700801313
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 HARRIS CT BLDG A
Provider Second Line Business Mailing Address:
STE A1
Provider Business Mailing Address City Name:
MONTEREY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93940-5704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-643-9788
Provider Business Mailing Address Fax Number:
831-657-0161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 HARRIS CT BLDG A
Provider Second Line Business Practice Location Address:
STE A1
Provider Business Practice Location Address City Name:
MONTEREY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93940-5704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-643-9788
Provider Business Practice Location Address Fax Number:
831-657-0161
Provider Enumeration Date:
07/13/2006

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: 207X00000X , with the licence number:  23186 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 49708 . This is a "EMPIRE BC" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: P00340986 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 187479 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4445600 . This is a "CIGNA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0442680 . This is a "AZ BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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