Provider Demographics
NPI:1043287220
Name:GRAHAM, MATTHEW TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TIMOTHY
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 631341
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-1341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 SAINT FRANCIS DR STE 360
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3972
Practice Address - Country:US
Practice Address - Phone:864-233-4349
Practice Address - Fax:877-417-0311
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD274472085R0202X
SC243292085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3852107Medicaid
4102717OtherBCBS
300110847OtherRR MEDICARE
TN3852108Medicaid
TN3852109Medicaid
P00264044OtherRR MEDICARE
3146921OtherBCBS
TNG94640Medicare UPIN
TN3852107Medicaid
300110847OtherRR MEDICARE
P00264044OtherRR MEDICARE