Provider Demographics
NPI:1225171895
Name:GRAHAM, TAMARA (DC)
Entity Type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MRS
Other - First Name:TAMARA
Other - Middle Name:GRAHAM
Other - Last Name:HEIDENBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:2431 RTE. 23 B
Mailing Address - City:SOUTH CAIRO
Mailing Address - State:NY
Mailing Address - Zip Code:12482-0037
Mailing Address - Country:US
Mailing Address - Phone:518-622-3960
Mailing Address - Fax:518-622-9384
Practice Address - Street 1:2431 RTE. 23 B
Practice Address - Street 2:
Practice Address - City:SOUTH CAIRO
Practice Address - State:NY
Practice Address - Zip Code:12482-0037
Practice Address - Country:US
Practice Address - Phone:518-622-3960
Practice Address - Fax:518-622-9384
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX005344-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX30401Medicare ID - Type Unspecified
NYT53206Medicare UPIN