Provider Demographics
NPI:1235237520
Name:GRAVES, KATHLEEN L (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:L
Last Name:GRAVES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:L
Other - Last Name:BIRDSONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3850 S NATIONAL AVE
Practice Address - Street 2:#400
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5287
Practice Address - Country:US
Practice Address - Phone:417-269-6850
Practice Address - Fax:417-269-5830
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6E59207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202105904Medicaid
5950OtherBLUE CROSS MO
MO202105904Medicaid
P00399417Medicare PIN
001012043Medicare PIN
160011715Medicare PIN
5950OtherBLUE CROSS MO