Provider Demographics
NPI:1932312956
Name:SUSAN BRANDT GRAHAM, MD, PHD, PC
Entity Type:Organization
Organization Name:SUSAN BRANDT GRAHAM, MD, PHD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:BRANDT
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:505-884-9488
Mailing Address - Street 1:4705 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1226
Mailing Address - Country:US
Mailing Address - Phone:505-884-9488
Mailing Address - Fax:505-884-7059
Practice Address - Street 1:4705 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE 102
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1226
Practice Address - Country:US
Practice Address - Phone:505-884-9488
Practice Address - Fax:505-884-7059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86-237207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME93889Medicare UPIN