Provider Demographics
NPI:1972585990
Name:GRAHAM, TERRENCE M (DPM,FACFAS)
Entity type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:M
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:DPM,FACFAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:102 W KENWOOD AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4368
Mailing Address - Country:US
Mailing Address - Phone:217-875-3668
Mailing Address - Fax:217-875-4277
Practice Address - Street 1:2 MEMORIAL DR STE 305
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3999
Practice Address - Country:US
Practice Address - Phone:217-876-4830
Practice Address - Fax:217-876-8385
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003032213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0060215009OtherBCBS
IL480008850OtherRR MEDICARE
IL016003032Medicaid
IL480008850OtherRR MEDICARE
IL016003032Medicaid