Healthcare Provider Details

I. General information

NPI: 1972725265
Provider Name (Legal Business Name): AUDREY E. GRAHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 RIVERMONT AVE
LYNCHBURG VA
24503-2030
US

IV. Provider business mailing address

3300 RIVERMONT AVE
LYNCHBURG VA
24503-2030
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-4072
  • Fax: 434-200-5546
Mailing address:
  • Phone: 434-200-4072
  • Fax: 434-200-5546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number000968
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101243718
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: