MEDICARE: SUSAN B GRAHAM INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	86-237	NM

General Provider Information

NPI Number	:	1023269198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSAN B GRAHAM INC

Provider Business Mailing Address
First Line	:	835 SPRUCE ST
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-3455
Country	:	US
Telephone Number	:	505-884-7059
Fax Number	:

Provider Business Practice Location Address
First Line	:	835 SPRUCE ST
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-3455
Country	:	US
Telephone Number	:	505-884-7059
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SUSAN B GRAHAM
Credential	:	MD
Telephone Number	:	505-884-7059

Provider Enumeration Date	:	10/07/2008
Last Update Date	:	10/07/2008

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Directions to “SUSAN B GRAHAM INC ” Practice Location

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