Healthcare Provider Details

I. General information

NPI: 1932592417
Provider Name (Legal Business Name): MARIE ELISE ROEBUCK GRAHAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 COMMISSIONERS ROAD E CHILDREN'S HOSPITAL, LONDON HEALTH SCIENCES CENTRE
LONDON ON
N6A 5W9
CA

IV. Provider business mailing address

800 COMMISSIONERS ROAD E, BOX 5010 CHILDREN'S HOSPITAL, LONDON HEALTH SCIENCES CENTRE
LONDON ON
N6A 5W9
CA

V. Phone/Fax

Practice location:
  • Phone: 902-473-2737
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number015863
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: