Provider Demographics
NPI:1932360815
Name:GRAHAM, SAMUEL LEROY
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:LEROY
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 1:14115 FRED AND AL KEY RD
Mailing Address - Street 2:
Mailing Address - City:KILN
Mailing Address - State:MS
Mailing Address - Zip Code:39556-8060
Mailing Address - Country:US
Mailing Address - Phone:228-466-1035
Mailing Address - Fax:228-466-8962
Practice Address - Street 1:14115 FRED AND AL KEY RD
Practice Address - Street 2:
Practice Address - City:KILN
Practice Address - State:MS
Practice Address - Zip Code:39556-8060
Practice Address - Country:US
Practice Address - Phone:228-466-1035
Practice Address - Fax:228-466-8962
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No286500000XHospitalsMilitary Hospital