Provider Demographics
NPI:1720118797
Name:JERRY M. GRAHAM, M.D.
Entity Type:Organization
Organization Name:JERRY M. GRAHAM, M.D.
Other - Org Name:GRAHAM MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-464-9080
Mailing Address - Street 1:2903 WALL TRIANA HWY STE 7
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35824-1537
Mailing Address - Country:US
Mailing Address - Phone:256-464-9080
Mailing Address - Fax:256-464-0193
Practice Address - Street 1:2903 WALL TRIANA HWY STE 7
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35824-1537
Practice Address - Country:US
Practice Address - Phone:256-464-9080
Practice Address - Fax:256-464-0193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7312207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALD32820Medicare UPIN
ALC70095Medicare UPIN