Provider Demographics
NPI:1639123904
Name:GRAHAM, MARY BETH (MD)
Entity type:Individual
Prefix:DR
First Name:MARY BETH
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:INFECTIOUS DISEASES
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-0746
Mailing Address - Fax:414-805-0748
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:INFECTIOUS DISEASES
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-0746
Practice Address - Fax:414-805-0748
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI43989207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
009000315ZOtherHUMANA
WI1639123904Medicaid
WI1639123904Medicaid
WI0060 73-601Medicare PIN