Healthcare Provider Details

I. General information

NPI: 1053441477
Provider Name (Legal Business Name): ROBERT L GRAVES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 RESERVOIR AVE SUITE 304
CRANSTON RI
02920-6068
US

IV. Provider business mailing address

1150 RESERVOIR AVE SUITE 304
CRANSTON RI
02920-6068
US

V. Phone/Fax

Practice location:
  • Phone: 401-942-3330
  • Fax: 401-942-3833
Mailing address:
  • Phone: 401-942-3330
  • Fax: 401-942-3833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2148
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO00688
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2148
License Number StateME
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO00688
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: