Provider Demographics
NPI:1427252584
Name:GRAHAM, GARTH NIGEL (MD)
Entity type:Individual
Prefix:
First Name:GARTH
Middle Name:NIGEL
Last Name:GRAHAM
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:PO BOX 505008
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5008
Mailing Address - Country:US
Mailing Address - Phone:816-502-7000
Mailing Address - Fax:
Practice Address - Street 1:4330 WORNALL RD
Practice Address - Street 2:SUITE 2000
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3201
Practice Address - Country:US
Practice Address - Phone:816-931-1883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219052207R00000X
FLME110458207R00000X
MO2016019591207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004002000Medicaid
FLFI486ZMedicare PIN