=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023168481
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRY S GRAVES M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 N MAYFAIR RD SUITE 220
-----------------------------------------------------
City | WAUWATOSA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53226-1409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-475-9101
-----------------------------------------------------
Fax | 414-475-9203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8104 BROOKSIDE PL
-----------------------------------------------------
City | WAUWATOSA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53213-3318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207K00000X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------