Provider Demographics
NPI:1205379609
Name:DAVID GRAHAM M.D., LLC
Entity Type:Organization
Organization Name:DAVID GRAHAM M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:CASSIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-567-7869
Mailing Address - Street 1:319 HOSPITAL DR
Mailing Address - Street 2:STE 208
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-1929
Mailing Address - Country:US
Mailing Address - Phone:276-656-2103
Mailing Address - Fax:
Practice Address - Street 1:319 HOSPITAL DR
Practice Address - Street 2:STE 208
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-1929
Practice Address - Country:US
Practice Address - Phone:276-656-2103
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-02
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty