Provider Demographics
NPI:1427097682
Name:GRABER, MARY EVELYN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:EVELYN
Last Name:GRABER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:707 E CEDAR ST
Mailing Address - Street 2:STE 200
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-472-6700
Mailing Address - Fax:574-472-6746
Practice Address - Street 1:611 E DOUGLAS
Practice Address - Street 2:SUITE 309
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1467
Practice Address - Country:US
Practice Address - Phone:574-252-2640
Practice Address - Fax:574-252-2650
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01031977208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000542787OtherBCBS
IN000000269216OtherBCBS
IN200069280AMedicaid
IN000000269216OtherBCBS