Provider Demographics
NPI:1952330557
Name:GRAHAM, STANLEY KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:KEITH
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 1:506 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-1906
Mailing Address - Country:US
Mailing Address - Phone:541-963-3138
Mailing Address - Fax:541-963-5918
Practice Address - Street 1:506 4TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-1906
Practice Address - Country:US
Practice Address - Phone:541-963-3138
Practice Address - Fax:541-963-5918
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15159207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORH1395 01OtherPACIFIC SOURCE
OR065268Medicaid
OR9305053253023OtherEMPLOYER ID
ORP00265707OtherRR MEDICARE
ORB18316Medicare UPIN
OR065268Medicaid