Healthcare Provider Details

I. General information

NPI: 1831278589
Provider Name (Legal Business Name): TRACY WARWICK GRAHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRACY MICHELLE WARWICK MD

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 MAIN ST STE 2A
KLAMATH FALLS OR
97601-6010
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 541-851-7350
  • Fax: 541-851-7351
Mailing address:
  • Phone: 605-328-6585
  • Fax: 605-328-6512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number23546
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier286410
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
IdentifierXPY197937
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: