Healthcare Provider Details

I. General information

NPI: 1699545251
Provider Name (Legal Business Name): EMILY ANNE GRAHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26300 WOODWARD AVE
ROYAL OAK MI
48067-0917
US

IV. Provider business mailing address

1030 HARRINGTON ST STE 101
MOUNT CLEMENS MI
48043-2967
US

V. Phone/Fax

Practice location:
  • Phone: 248-336-4000
  • Fax: 248-336-9137
Mailing address:
  • Phone: 586-464-4010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601013006
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: