Provider Demographics
NPI:1205831666
Name:GRAHAM, BOBBY L JR (MD)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:L
Last Name:GRAHAM
Suffix:JR
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 1:1227 N STATE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2002
Mailing Address - Country:US
Mailing Address - Phone:601-355-2485
Mailing Address - Fax:601-353-1463
Practice Address - Street 1:2969 CURRAN DR N
Practice Address - Street 2:STE 200
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4121
Practice Address - Country:US
Practice Address - Phone:601-974-5600
Practice Address - Fax:601-974-5699
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10277207RH0002X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4225962OtherAETNA HEALTHCARE
MS000115226Medicaid
MS00115226Medicaid
B29977Medicare UPIN
4225962OtherAETNA HEALTHCARE