Healthcare Provider Details

I. General information

NPI: 1821081860
Provider Name (Legal Business Name): ERROL G GRAHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E TOLLISON ST STE C
BAXLEY GA
31513-0150
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 912-367-4122
  • Fax: 912-367-4136
Mailing address:
  • Phone:
  • Fax: 904-450-6401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number032388
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: