Provider Demographics
NPI:1063864056
Name:GRAVES GILBERT CLINIC PLLC
Entity type:Organization
Organization Name:GRAVES GILBERT CLINIC PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:DERAMO
Authorized Official - Suffix:
Authorized Official - Credentials:DHA
Authorized Official - Phone:270-780-0549
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1708
Mailing Address - Country:US
Mailing Address - Phone:270-781-5111
Mailing Address - Fax:270-783-0454
Practice Address - Street 1:165 NATCHEZ TRACE AVE STE 100
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7947
Practice Address - Country:US
Practice Address - Phone:270-782-7800
Practice Address - Fax:270-843-0779
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GGC HEALTH, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-01
Last Update Date:2025-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYHME01042332B00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies