Provider Demographics
NPI:1598718165
Name:MENDOCINO MEDICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:MENDOCINO MEDICAL ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-964-7241
Mailing Address - Street 1:721 RIVER DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT BRAGG
Mailing Address - State:CA
Mailing Address - Zip Code:95437-5402
Mailing Address - Country:US
Mailing Address - Phone:707-964-7241
Mailing Address - Fax:707-961-1192
Practice Address - Street 1:721 RIVER DR
Practice Address - Street 2:SUITE A
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5402
Practice Address - Country:US
Practice Address - Phone:707-964-7241
Practice Address - Fax:707-961-1192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG35252207Q00000X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0060500Medicaid
CARHM53828FMedicaid
CAGR0060500Medicaid