Provider Demographics
NPI:1023182375
Name:GRAHEK, MARY MARTHA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MARTHA
Last Name:GRAHEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-5109
Mailing Address - Country:US
Mailing Address - Phone:218-263-1000
Mailing Address - Fax:
Practice Address - Street 1:730 E 34TH ST
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-5109
Practice Address - Country:US
Practice Address - Phone:218-263-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32272207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN898305400Medicaid
MN080007207Medicare PIN
E72599Medicare UPIN