Healthcare Provider Details

I. General information

NPI: 1124025663
Provider Name (Legal Business Name): THERESA A. GRAVES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY ST SUITE 470
PROVIDENCE RI
02905-3236
US

IV. Provider business mailing address

PO BOX 16149
RUMFORD RI
02916-0697
US

V. Phone/Fax

Practice location:
  • Phone: 401-553-8304
  • Fax: 401-868-2304
Mailing address:
  • Phone: 401-453-9625
  • Fax: 401-435-7069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD08747
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: