Provider Demographics
NPI:1508862020
Name:GRAHAM, JEFFREY S (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 UNION ST
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605-1534
Mailing Address - Country:US
Mailing Address - Phone:207-664-5455
Mailing Address - Fax:207-664-5456
Practice Address - Street 1:50 UNION ST
Practice Address - Street 2:SUITE 1400
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605-1534
Practice Address - Country:US
Practice Address - Phone:207-664-5455
Practice Address - Fax:207-664-5456
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015009208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME434423299Medicaid
ME434423299Medicaid
MEF84133Medicare UPIN
MEMM7722Medicare ID - Type UnspecifiedRENDERING PROVIDER ID
MEMM772202Medicare PIN