Provider Demographics
NPI:1790752640
Name:GRAHAM, TANITH M (MD)
Entity Type:Individual
Prefix:DR
First Name:TANITH
Middle Name:M
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-1196
Mailing Address - Fax:601-984-5939
Practice Address - Street 1:2869 SW CHAMPLAIN DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-5833
Practice Address - Country:US
Practice Address - Phone:503-709-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13201207L00000X, 207LP2900X
MS09591207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1037381Medicaid
MN7394381-00Medicaid
MS02121230Medicaid
OR050032614OtherRR MEDICARE
OR117006Medicaid
OR117006Medicaid