Provider Demographics
NPI:1326188764
Name:GRAHAM, MARCIA K (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCIA
Middle Name:K
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:3231 S NATIONAL AVE
Practice Address - Street 2:SUITE 280
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7304
Practice Address - Country:US
Practice Address - Phone:417-885-0834
Practice Address - Fax:417-888-6763
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO114945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203756002Medicaid
AR83136OtherARK BLUE SHIELD
MO138416OtherMO BLUE SHIELD
114945Medicare UPIN
MO064013230Medicare PIN
MO138416OtherMO BLUE SHIELD