Provider Demographics
NPI:1427274976
Name:GRAHAM, SUSAN JOY (MD)
Entity type:Individual
Prefix:MR
First Name:SUSAN
Middle Name:JOY
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:899 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:OH
Mailing Address - Zip Code:44890-9741
Mailing Address - Country:US
Mailing Address - Phone:419-933-6710
Mailing Address - Fax:
Practice Address - Street 1:815 NORTHWEST ST
Practice Address - Street 2:BUILDING B, SECOND FLOOR
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811-1074
Practice Address - Country:US
Practice Address - Phone:419-483-4040
Practice Address - Fax:419-483-2192
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-067246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0110687Medicaid
OHG00279Medicare UPIN
OHGR7326211Medicare ID - Type Unspecified