Provider Demographics
NPI:1629709076
Name:GRAVES, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GRAVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ROUTE 37 E STE 4
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:CT
Mailing Address - Zip Code:06784-1408
Mailing Address - Country:US
Mailing Address - Phone:212-621-9008
Mailing Address - Fax:
Practice Address - Street 1:1 ROUTE 37 E STE 4
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:CT
Practice Address - Zip Code:06784-1408
Practice Address - Country:US
Practice Address - Phone:212-621-9008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch