Provider Demographics
NPI:1083708937
Name:GRAHAM, BRYAN BURK (DC, CCSP)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:BURK
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 LONG POND RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2606
Mailing Address - Country:US
Mailing Address - Phone:508-747-1434
Mailing Address - Fax:508-747-0772
Practice Address - Street 1:34 LONG POND RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2606
Practice Address - Country:US
Practice Address - Phone:508-747-1434
Practice Address - Fax:508-747-0772
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2158111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1608550Medicaid
MA28387OtherCIGNA
MA3303802OtherAETNA
MA352411OtherHARVARD PILGRIM HEALTH CA
MAY36728OtherBCBS OF MA
MA4401065OtherUNITED HEALTH CARE
MA698922OtherSECURE HORIZONS
MA470633OtherTUFTS
MA3303802OtherAETNA
MA352411OtherHARVARD PILGRIM HEALTH CA