Provider Demographics
NPI:1861572117
Name:GRAHAM, BRETT HARRISON (MD, PHD)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:HARRISON
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1002 WISHARD BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-4163
Practice Address - Country:US
Practice Address - Phone:317-944-3966
Practice Address - Fax:317-968-1354
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6918207SG0201X, 208000000X
IN01078449A207SG0202X, 207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No207SG0202XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Biochemical Genetics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300004246Medicaid
IN000001105334OtherANTHEM PTAN
TX162909901Medicaid
H98799Medicare UPIN
TX81J260Medicare PIN