Provider Demographics
NPI:1881697902
Name:GRAHAM, GENE S
Entity type:Individual
Prefix:DR
First Name:GENE
Middle Name:S
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1871 W WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-2255
Mailing Address - Country:US
Mailing Address - Phone:740-363-4373
Mailing Address - Fax:740-363-9560
Practice Address - Street 1:1871 W WILLIAM ST
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-2255
Practice Address - Country:US
Practice Address - Phone:740-363-4373
Practice Address - Fax:740-363-9560
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1839213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0344274-1221Medicaid
OH31-1062667OtherTAX ID
OH0181090001Medicare NSC
OH31-1062667OtherTAX ID
OHT80445Medicare UPIN