Provider Demographics
NPI:1164039772
Name:GRAHAM, RUSSELL P
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:P
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 NORTH ROAD
Mailing Address - Street 2:
Mailing Address - City:NORTH YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04097
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 NORTH ROAD
Practice Address - Street 2:
Practice Address - City:NORTH YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04097
Practice Address - Country:US
Practice Address - Phone:207-239-6625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP5800824-02OtherPERSONAL INSURANCE