Healthcare Provider Details

I. General information

NPI: 1295313260
Provider Name (Legal Business Name): ERIC GRAHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2021
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 W WATERTOWN PLANK RD
MILWAUKEE WI
53226-3548
US

IV. Provider business mailing address

8701 W WATERTOWN PLANK RD
MILWAUKEE WI
53226-3548
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-6450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number81868-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: