Provider Demographics
NPI:1861452104
Name:GRAHAM, SCOTT FITZGERALD (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:FITZGERALD
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 1:6775 CROSSWINDS DR N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-5471
Mailing Address - Country:US
Mailing Address - Phone:727-381-8006
Mailing Address - Fax:727-381-9629
Practice Address - Street 1:1175 WILSON AVE NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49534-6407
Practice Address - Country:US
Practice Address - Phone:616-685-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301106753207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270722500Medicaid
FLH79406Medicare UPIN
FL62753Medicare ID - Type Unspecified