Healthcare Provider Details

I. General information

NPI: 1205149879
Provider Name (Legal Business Name): GRAHAM UROLOGICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2010
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 ESTATE PETERS RST STE 1
CHRISTIANSTED VI
00820-5817
US

IV. Provider business mailing address

PO BOX 6883
CHRISTIANSTED VI
00823-6883
US

V. Phone/Fax

Practice location:
  • Phone: 340-719-8761
  • Fax:
Mailing address:
  • Phone: 340-719-8761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1455
License Number StateVI

VIII. Authorized Official

Name: DR. EMMANUEL S GRAHAM
Title or Position: DIRECTOR
Credential: M.D
Phone: 340-719-8761