Provider Demographics
NPI:1306406863
Name:GRAHAM, JACK
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:
Last Name:GRAHAM
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 1:8401 MARKET STREET
Mailing Address - Street 2:DEPARTMENT OF MEDICAL EDUCATION
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03756-0001
Practice Address - Country:US
Practice Address - Phone:603-650-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH23856207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine