Provider Demographics
NPI:1114948288
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:
Authorized Official - Phone:614-499-0667
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:270-783-3750
Practice Address - Street 1:201 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1742
Practice Address - Country:US
Practice Address - Phone:270-781-5111
Practice Address - Fax:270-783-3750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
183500000X, 152W00000X, 103G00000X, 231H00000X, 208M00000X, 363L00000X, 225100000X, 332B00000X, 332900000X, 291U00000X, 363A00000X, 174400000X
KY225X00000X, 207T00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No332900000XSuppliersNon-Pharmacy Dispensing SiteGroup - Multi-Specialty
No207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYCC0284OtherMEDICARE RAILROAD
KY65908766Medicaid
KY0584320001OtherDME MEDICARE
KYCC0284OtherMEDICARE RAILROAD
KYCC0284OtherMEDICARE RAILROAD
5353Medicare PIN
6411Medicare PIN
KY0584320001OtherDME MEDICARE
8183Medicare PIN
5352Medicare PIN
KY65908766Medicaid
7540Medicare PIN
5346Medicare PIN
5351Medicare PIN
5345Medicare PIN
4374Medicare PIN