Healthcare Provider Details

I. General information

NPI: 1538177407
Provider Name (Legal Business Name): IRENE L GRAHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 02/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S GRAND BLVD DRC 1ST FLOOR
SAINT LOUIS MO
63104-1015
US

IV. Provider business mailing address

1100 S GRAND BLVD DRC 1ST FLOOR
SAINT LOUIS MO
63104-1015
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-6333
  • Fax: 314-977-6340
Mailing address:
  • Phone: 314-977-6333
  • Fax: 314-977-6340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberR1F55
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: