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1063864056 NPI number — GRAVES GILBERT CLINIC PLLC

NPI Number: 1063864056
Health Care Provider/Practitioner: GRAVES GILBERT CLINIC PLLC

Information about “1063864056” NPI (GRAVES GILBERT CLINIC PLLC) exists in 1063864056 in HTML format HTML  |  1063864056 in plain Text format TXT  |  1063864056 in PDF (Portable Document Format) PDF  |  1063864056 in an XML format XML  formats.

NPI Number : 1063864056 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1063864056",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "Y",
    "ParentOrgLBN": "GGC HEALTH, PLLC",
    "ParentOrgTIN": null,
    "OrgName": "GRAVES GILBERT CLINIC PLLC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": "6",
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "201 PARK ST",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "BOWLING GREEN",
    "MailingAddressStateName": "KY",
    "MailingAddressPostalCode": "42101-1708",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "270-781-5111",
    "MailingAddressFaxNumber": "270-783-0454",
    "FirstLinePracticeLocationAddress": "165 NATCHEZ TRACE AVE STE 100",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "BOWLING GREEN",
    "PracticeLocationAddressStateName": "KY",
    "PracticeLocationAddressPostalCode": "42103-7947",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "270-782-7800",
    "PracticeLocationAddressFaxNumber": "270-843-0779",
    "EnumerationDate": "07/01/2016",
    "LastUpdateDate": "10/22/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "DERAMO",
    "AuthorizedOfficialFirstName": "MICHAEL",
    "AuthorizedOfficialMiddleName": "E",
    "AuthorizedOfficialTitle": "CEO",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "DHA",
    "AuthorizedOfficialTelephoneNumber": "270-780-0549",
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "332B00000X",
          "TaxonomyName": "Durable Medical Equipment & Medical Supplies",
          "LicenseNumber": "HME01042",
          "LicenseNumberStateCode": "KY",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "332B00000X",
          "TaxonomyName": "Durable Medical Equipment & Medical Supplies",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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