MEDICARE: GLENN E. GRAVES M.D.

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	207W00000X	Ophthalmology Physician	27890-020	WI
2	207WX0009X	Glaucoma Specialist (Ophthalmology) Physician	27890-020	WI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	180020621	OTHER	WI	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	391484998011	OTHER	WI	BLUE CROSS
3	391484998C	OTHER	WI	HUMANA
4	0800065	OTHER	WI	PRIMECARE
5	391484998	OTHER	WI	TAX ID
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780671677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN E. GRAVES M.D.

Provider Business Mailing Address
First Line	:	6020 S PACKARD AVE
Second Line	:
City	:	CUDAHY
State	:	WI
Zip	:	53110-3028
Country	:	US
Telephone Number	:	414-294-4660
Fax Number	:	414-281-0959

Provider Business Practice Location Address
First Line	:	4600 W LOOMIS RD STE 310
Second Line	:
City	:	GREENFIELD
State	:	WI
Zip	:	53220-4858
Country	:	US
Telephone Number	:	414-281-0963
Fax Number	:	414-281-0959

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	04/23/2024

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Directions to “ GLENN E. GRAVES M.D.” Practice Location

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