Provider Demographics
NPI:1265643357
Name:GRAVES DERMA CARE CENTER PC
Entity Type:Organization
Organization Name:GRAVES DERMA CARE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VAUGHAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-879-2389
Mailing Address - Street 1:3900 FORD RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-2039
Mailing Address - Country:US
Mailing Address - Phone:215-879-2389
Mailing Address - Fax:215-879-2575
Practice Address - Street 1:1020 KINGS HWY N
Practice Address - Street 2:SUITE 101
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1906
Practice Address - Country:US
Practice Address - Phone:856-321-0001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA024209Medicare PIN