MEDICARE: BRUCE W GRAHAM MD

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	207RC0000X	Cardiovascular Disease Physician	35045972G	OH

General Provider Information

NPI Number	:	1811982838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE W GRAHAM MD

Provider Business Mailing Address
First Line	:	5969 E BROAD ST
Second Line	:	STE 202
City	:	COLUMBUS
State	:	OH
Zip	:	43213-1546
Country	:	US
Telephone Number	:	614-863-1692
Fax Number	:	614-575-5382

Provider Business Practice Location Address
First Line	:	477 COOPER RD
Second Line	:	STE 400
City	:	WESTERVILLE
State	:	OH
Zip	:	43081-8053
Country	:	US
Telephone Number	:	614-865-4050
Fax Number	:	614-575-5382

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

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	01/04/2011

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