Provider Demographics
NPI:1285730952
Name:JACK L GRAHAM, MD, PC
Entity type:Organization
Organization Name:JACK L GRAHAM, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-623-8100
Mailing Address - Street 1:1600 SE MAIN ST STE E
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-5423
Mailing Address - Country:US
Mailing Address - Phone:505-623-8100
Mailing Address - Fax:505-623-8101
Practice Address - Street 1:1600 SE MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-5423
Practice Address - Country:US
Practice Address - Phone:505-623-8100
Practice Address - Fax:505-623-8101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM74-39207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM11023Medicaid
NM11023Medicaid
NMD35666Medicare UPIN