Healthcare Provider Details

I. General information

NPI: 1336121987
Provider Name (Legal Business Name): MARY V GRAHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY LEE VOGELSANG MD

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10010 KENNERLY RD
SAINT LOUIS MO
63128-2106
US

IV. Provider business mailing address

11475 OLDE CABIN RD STE 200
SAINT LOUIS MO
63141-7129
US

V. Phone/Fax

Practice location:
  • Phone: 314-525-1688
  • Fax: 314-525-1689
Mailing address:
  • Phone: 314-991-8200
  • Fax: 314-991-8206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberR3M43
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: