Provider Demographics
NPI:1558462218
Name:GRAHAM, ERIC J (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:J
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6300 E LAKE BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6770
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:228-206-1192
Practice Address - Street 1:15476 DEDEAUX RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2637
Practice Address - Country:US
Practice Address - Phone:228-230-2663
Practice Address - Fax:228-679-3038
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MS17733207X00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126157Medicaid
MSP00285790OtherRAILROAD MEDICARE
MSP00285790OtherRAILROAD MEDICARE
MSH68214Medicare UPIN