Provider Demographics
NPI:1457559692
Name:GRAHAM, KEVIN T (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:T
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 1:1264 WEAVER DR
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43023-1257
Mailing Address - Country:US
Mailing Address - Phone:220-564-1950
Mailing Address - Fax:220-564-1951
Practice Address - Street 1:1264 WEAVER DR
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:OH
Practice Address - Zip Code:43023-1257
Practice Address - Country:US
Practice Address - Phone:220-564-1950
Practice Address - Fax:220-564-1951
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.096582207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3114105Medicaid
OHH276610Medicare PIN