Healthcare Provider Details

I. General information

NPI: 1922289107
Provider Name (Legal Business Name): PHILIP DOUGLAS GRAHAM PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 BUFFALO ROAD SUITE 1
NORTH CHILI NY
14514-1256
US

IV. Provider business mailing address

PO BOX 505
NORTH CHILLI NY
14514-0505
US

V. Phone/Fax

Practice location:
  • Phone: 585-594-5995
  • Fax: 585-594-5995
Mailing address:
  • Phone: 585-594-5995
  • Fax: 585-594-5425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number012180
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number012180
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: