Healthcare Provider Details

I. General information

NPI: 1972679322
Provider Name (Legal Business Name): PERINATAL MEDICINE ASSOCIATES, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W COLLEGE ST SUITE 210
GRAPEVINE TX
76051-3580
US

IV. Provider business mailing address

PO BOX 100186
FORT WORTH TX
76185-0186
US

V. Phone/Fax

Practice location:
  • Phone: 817-481-0111
  • Fax: 817-481-0112
Mailing address:
  • Phone: 817-731-7771
  • Fax: 817-731-7774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JACK MONROE GRAHAM
Title or Position: MD
Credential: MD
Phone: 817-481-0111