Provider Demographics
NPI:1194795393
Name:GRAFF, RUSSELL JAY (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JAY
Last Name:GRAFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 JODORE AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-2768
Mailing Address - Country:US
Mailing Address - Phone:419-536-5186
Mailing Address - Fax:
Practice Address - Street 1:5901 MONCLOVA RD
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1855
Practice Address - Country:US
Practice Address - Phone:419-893-5968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073595207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2176998Medicaid
OH000000281779OtherANTHEM
OHGR0874303Medicare PIN
OHG92869Medicare UPIN
OH2176998Medicaid