Provider Demographics
NPI:1043376148
Name:GRAHAM, SAMUEL LYLE III (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:LYLE
Last Name:GRAHAM
Suffix:III
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 1:1900 LONLIPMAN CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-1732
Mailing Address - Country:US
Mailing Address - Phone:502-897-6039
Mailing Address - Fax:
Practice Address - Street 1:1900 LONLIPMAN CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-1732
Practice Address - Country:US
Practice Address - Phone:502-897-6039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18158207R00000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY538148OtherBCBS
KY64181589Medicaid
KY1061538OtherPASSPORT
KY1971401Medicare PIN
KY1061538OtherPASSPORT