Provider Demographics
NPI:1598734659
Name:GRAHAM, BRUCE M (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
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 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 W UNIVERSITY AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3400
Practice Address - Country:US
Practice Address - Phone:765-281-2000
Practice Address - Fax:765-281-2062
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01039362A207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00413052OtherMEDICARE RROAD
IN100107270BMedicaid
IN060033596OtherMEDICARE B-RAILROAD
IN100107270BMedicaid
IN208790NMedicare PIN
INP00413052OtherMEDICARE RROAD
INM22404037Medicare PIN