Provider Demographics
NPI:1386941300
Name:GRAHAM WELLNESS MEDICAL, P.C.
Entity type:Organization
Organization Name:GRAHAM WELLNESS MEDICAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:718-566-0022
Mailing Address - Street 1:104 GRAHAM AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-3320
Mailing Address - Country:US
Mailing Address - Phone:718-218-6616
Mailing Address - Fax:718-218-6634
Practice Address - Street 1:104 GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-3320
Practice Address - Country:US
Practice Address - Phone:718-218-6616
Practice Address - Fax:718-218-6634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty