MEDICARE: MR. SCOTT DAVID GRAHAM HM IDC

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	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1932312097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SCOTT DAVID GRAHAM HM IDC

Provider Business Mailing Address
First Line	:	EODMU 5 UNIT 25499
Second Line	:	2112 SUMAY COVE DRIVE
City	:	SANTA RITA
State	:	GUAM
Zip	:	96915
Country	:	UM
Telephone Number	:	671-339-8171
Fax Number	:	671-339-8179

Provider Business Practice Location Address
First Line	:	EODMU 5 UNIT 25499
Second Line	:	2112 SUMAY COVE DRIVE
City	:	SANTA RITA
State	:	GAUM
Zip	:	96915
Country	:	UM
Telephone Number	:	671-339-8171
Fax Number	:	671-339-8179

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

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	07/08/2007

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