Provider Demographics
NPI:1518155258
Name:AUDREY L. GRAHAM, MD, PA
Entity Type:Organization
Organization Name:AUDREY L. GRAHAM, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:KANNADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-613-5379
Mailing Address - Street 1:3310 LIVE OAK ST
Mailing Address - Street 2:400
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-6147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3310 LIVE OAK ST
Practice Address - Street 2:400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6147
Practice Address - Country:US
Practice Address - Phone:214-823-6500
Practice Address - Fax:214-823-6816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7060174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX141549901Medicaid
TX141549901Medicaid
00029RMedicare PIN