Provider Demographics
NPI:1336328780
Name:BERTRAM ANTHONY GRAVES, MD, PC
Entity Type:Organization
Organization Name:BERTRAM ANTHONY GRAVES, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERTRAM
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-584-4000
Mailing Address - Street 1:3737 N MERIDIAN ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4348
Mailing Address - Country:US
Mailing Address - Phone:317-584-4000
Mailing Address - Fax:317-584-4008
Practice Address - Street 1:3737 N MERIDIAN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4348
Practice Address - Country:US
Practice Address - Phone:317-584-4000
Practice Address - Fax:317-584-4008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039628207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100120680Medicaid
IN100120680Medicaid
INA49334Medicare UPIN