Healthcare Provider Details

I. General information

NPI: 1164039772
Provider Name (Legal Business Name): RUSSELL P GRAHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 09/28/2020
Certification Date: 09/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 NORTH ROAD
NORTH YARMOUTH ME
04097
US

IV. Provider business mailing address

1500 NORTH ROAD
NORTH YARMOUTH ME
04097
US

V. Phone/Fax

Practice location:
  • Phone: 207-239-6625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: