Provider Demographics
NPI:1417015827
Name:GRAVEN, TIMOTHY G (DO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:G
Last Name:GRAVEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-0008
Mailing Address - Country:US
Mailing Address - Phone:636-441-3444
Mailing Address - Fax:636-441-9832
Practice Address - Street 1:112 PIPER HILL DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1690
Practice Address - Country:US
Practice Address - Phone:636-441-3444
Practice Address - Fax:636-441-9832
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2F62207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOC52049Medicare UPIN
MO000095455Medicare ID - Type UnspecifiedMEDICARE ID