Provider Demographics
NPI:1245258482
Name:GRAHAM, MARK G (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:GRAHAM
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Gender:M
Credentials:MD
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Mailing Address - Street 1:2301 S BROAD ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-3542
Mailing Address - Country:US
Mailing Address - Phone:215-551-8660
Mailing Address - Fax:215-551-9247
Practice Address - Street 1:2301 S BROAD ST
Practice Address - Street 2:SUITE 205
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-3542
Practice Address - Country:US
Practice Address - Phone:215-551-8660
Practice Address - Fax:215-551-9247
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-03-24
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Provider Licenses
StateLicense IDTaxonomies
PAMD-022223-E207R00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000810360Medicaid
NJ7569106Medicaid
PA022749Medicare PIN