Provider Demographics
NPI:1821186933
Name:GRAVES, BERTRAM ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:BERTRAM
Middle Name:ANTHONY
Last Name:GRAVES
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 1:3737 N. MERIDIAN ST.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4357
Mailing Address - Country:US
Mailing Address - Phone:317-584-4000
Mailing Address - Fax:317-584-4008
Practice Address - Street 1:3737 N. MERIDIAN ST.
Practice Address - Street 2:SUITE 104
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4357
Practice Address - Country:US
Practice Address - Phone:317-584-4000
Practice Address - Fax:317-584-4008
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039628207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100120680Medicaid
INA49334Medicare UPIN
IN277460AMedicare ID - Type Unspecified
IN100120680Medicaid