Provider Demographics
NPI:1013905231
Name:GRAHAM MEDICAL CLINIC
Entity Type:Organization
Organization Name:GRAHAM MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAOUF
Authorized Official - Middle Name:F
Authorized Official - Last Name:MAOUD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-847-9166
Mailing Address - Street 1:PO BOX 1188
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-1188
Mailing Address - Country:US
Mailing Address - Phone:253-847-9166
Mailing Address - Fax:253-847-6406
Practice Address - Street 1:21120 MERIDIAN AVE E
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:WA
Practice Address - Zip Code:98338-8254
Practice Address - Country:US
Practice Address - Phone:253-847-9166
Practice Address - Fax:253-847-6406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00032553207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8176968Medicaid
WA8176968Medicaid
WAGAB24872Medicare PIN