Healthcare Provider Details

I. General information

NPI: 1780680058
Provider Name (Legal Business Name): GEORGE N. GRAVES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 05/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 CATES STREET
DUNLAP TN
37327-1777
US

IV. Provider business mailing address

PO BOX 1777
DUNLAP TN
37327-1777
US

V. Phone/Fax

Practice location:
  • Phone: 423-949-2171
  • Fax: 423-949-5118
Mailing address:
  • Phone: 423-949-2171
  • Fax: 423-949-5118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO691
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: