Provider Demographics
NPI:1710094180
Name:GRAHAM, RANDAL OLIVER (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:OLIVER
Last Name:GRAHAM
Suffix:
Gender:M
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:PO BOX 52948
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-2948
Mailing Address - Country:US
Mailing Address - Phone:865-306-5675
Mailing Address - Fax:865-584-7712
Practice Address - Street 1:1819 W CLINCH AVE STE 200
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2435
Practice Address - Country:US
Practice Address - Phone:865-524-3695
Practice Address - Fax:865-602-3528
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 17921208600000X
TNMD179212086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3026054Medicaid
TN3026054Medicaid
3026057Medicare PIN