Provider Demographics
NPI:1275028649
Name:GRAIG, KENNETH MARK
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MARK
Last Name:GRAIG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MANSION DR
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12538-1110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 MANSION DR
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:12538
Practice Address - Country:US
Practice Address - Phone:845-233-5109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-27
Last Update Date:2018-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY353920174400000X
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty