Provider Demographics
NPI:1669476370
Name:GRAHAM, CAROL ANN (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 S WOODS MILL RD
Mailing Address - Street 2:STE 55W
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-3662
Mailing Address - Country:US
Mailing Address - Phone:314-205-6402
Mailing Address - Fax:314-590-5951
Practice Address - Street 1:226 S WOODS MILL RD
Practice Address - Street 2:STE 55W
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-3662
Practice Address - Country:US
Practice Address - Phone:314-205-6402
Practice Address - Fax:314-590-5951
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36345207VG0400X, 208800000X
KY36346207VF0040X
MO20140367832088F0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088F0040XAllopathic & Osteopathic PhysiciansUrologyFemale Pelvic Medicine and Reconstructive Surgery
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No208800000XAllopathic & Osteopathic PhysiciansUrology
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY142082OtherSIHO - WS
IN200308410Medicaid
KY000000798069OtherANTHEM - WOMEN'S SPECIALISTS
KY000000667083OtherANTHEM
KY50044196OtherPASSPORT - WS
KY64031370Medicaid
MOMA5406001Medicare PIN
KYK066020Medicare PIN
KY000000667083OtherANTHEM
KY000000798069OtherANTHEM - WOMEN'S SPECIALISTS
KY64031370Medicaid