Provider Demographics
NPI:1265484919
Name:GRAHAM, RUSSELL M (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:M
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 1:119 PLEASANT LAKE CT
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-6864
Mailing Address - Country:US
Mailing Address - Phone:573-204-1046
Mailing Address - Fax:
Practice Address - Street 1:119 PLEASANT LAKE CT
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-6864
Practice Address - Country:US
Practice Address - Phone:573-204-1046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO2007034232207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD58035Medicare UPIN