Provider Demographics
NPI:1083625511
Name:GRAHAM, R. MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:R.
Middle Name:MICHAEL
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 1:100 KINGSLEY LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4604
Mailing Address - Country:US
Mailing Address - Phone:757-889-6580
Mailing Address - Fax:757-889-6583
Practice Address - Street 1:100 KINGSLEY LN
Practice Address - Street 2:SUITE 300
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4604
Practice Address - Country:US
Practice Address - Phone:757-889-6580
Practice Address - Fax:757-889-6583
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044491207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010140811Medicaid
VAE11839Medicare UPIN
VA010140811Medicaid
VA00W310001Medicare PIN