Provider Demographics
NPI:1528084464
Name:GRAHAM, IAN R (MD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:R
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 2153 DEPT 30755
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35287-9283
Mailing Address - Country:US
Mailing Address - Phone:314-238-5260
Mailing Address - Fax:314-821-1833
Practice Address - Street 1:HENRY COUNTY MEDICAL CENTER
Practice Address - Street 2:301 TYSON AVENUE
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38424
Practice Address - Country:US
Practice Address - Phone:731-644-8535
Practice Address - Fax:731-642-9588
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361074292085R0202X
MO20020157422085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
300133434OtherRAILROAD MEDICARE NUMBER
MO205942303Medicaid
MO034010350Medicare ID - Type UnspecifiedMO MEDICARE NUMBER
300133434OtherRAILROAD MEDICARE NUMBER
H63400Medicare UPIN
ILL94379Medicare ID - Type UnspecifiedIL MEDICARE NUMBER