Provider Demographics
NPI:1225092794
Name:GRAHAM, RICHARD W (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:W
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 1:44 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-1381
Mailing Address - Country:US
Mailing Address - Phone:802-728-2372
Mailing Address - Fax:802-728-2613
Practice Address - Street 1:108 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05001-7056
Practice Address - Country:US
Practice Address - Phone:802-296-7370
Practice Address - Fax:802-296-7174
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101 033452208800000X
VT042-0012170208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1225092794Medicaid
VA24388OtherALLIANCE
NH32000393Medicaid
VA59294OtherSOUTHERN HEALTH
VA2582OtherCIGNA
VA340001591OtherRAILROAD MEDICARE
VA447989OtherSOUTHERN HEALTH EFF111506
VA45722OtherSENTARA FAMILY CARE
VA1900011OtherUNITED HEALTHCARE
VA36538OtherCARENET
VA3762531OtherAETNA HMO
VA4063408OtherAETNA PPO
VA497602109OtherTRICARE
VA247815OtherANTHEM BCBS
VT3016615OtherMVP
002130301OtherMEDICARE PTAN
VT1478176OtherCIGNA
VT1018994Medicaid
VA642070000-00OtherQUALCHOICE
VA66241OtherCARENET EFF 111506
VT1478176OtherCIGNA
VA2582OtherCIGNA
VA66241OtherCARENET EFF 111506