Healthcare Provider Details

I. General information

NPI: 1851599211
Provider Name (Legal Business Name): JEREMY ROBERT GRAHAM D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 ALCORN DR
CORINTH MS
38834-9321
US

IV. Provider business mailing address

135 EDGEWATER DR
SALTILLO MS
38866-7945
US

V. Phone/Fax

Practice location:
  • Phone: 662-293-1000
  • Fax: 662-287-2823
Mailing address:
  • Phone: 769-798-2710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number20175
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: