Healthcare Provider Details

I. General information

NPI: 1780680363
Provider Name (Legal Business Name): JOHN MAITLAND GRAHAM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 LINCOLN WAY E
OSCEOLA IN
46561-2767
US

IV. Provider business mailing address

320 LINCOLN WAY E
OSCEOLA IN
46561-2767
US

V. Phone/Fax

Practice location:
  • Phone: 574-674-6700
  • Fax: 574-674-7171
Mailing address:
  • Phone: 574-674-6700
  • Fax: 574-674-7171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number02001454A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: