Healthcare Provider Details

I. General information

NPI: 1710094180
Provider Name (Legal Business Name): RANDAL OLIVER GRAHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 W CLINCH AVE STE 200
KNOXVILLE TN
37916-2435
US

IV. Provider business mailing address

PO BOX 52948
KNOXVILLE TN
37950-2948
US

V. Phone/Fax

Practice location:
  • Phone: 865-524-3695
  • Fax: 865-602-3528
Mailing address:
  • Phone: 865-306-5675
  • Fax: 865-584-7712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD 17921
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD17921
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: