Healthcare Provider Details

I. General information

NPI: 1871692582
Provider Name (Legal Business Name): STANLEY C GRAVES M D PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5080 N 40TH ST STE 103
PHOENIX AZ
85018-2158
US

IV. Provider business mailing address

3104 E CAMELBACK RD # 1003
PHOENIX AZ
85016-4502
US

V. Phone/Fax

Practice location:
  • Phone: 602-952-8111
  • Fax: 602-952-1572
Mailing address:
  • Phone: 602-952-8111
  • Fax: 602-952-1572

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number22387
License Number StateAZ

VIII. Authorized Official

Name: STANLEY CECIL GRAVES
Title or Position: OWNER
Credential: M.D.
Phone: 602-952-8111