Provider Demographics
NPI:1336142561
Name:GRAHAM, MARY MARGARET (DPM)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:MARGARET
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 ALLEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-1457
Mailing Address - Country:US
Mailing Address - Phone:740-775-7800
Mailing Address - Fax:740-773-8545
Practice Address - Street 1:1130 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-1174
Practice Address - Country:US
Practice Address - Phone:740-775-7800
Practice Address - Fax:740-773-8545
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003331G213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2413721Medicaid
OHU95288Medicare UPIN
OH2413721Medicaid