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General NPI Number Information
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NPI Number | 1205941119
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Entity Type | Organization
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Legal Business Name | RUSSELL M GRAHAM MD PA
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Dates
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Enumeration Date | 08/20/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 679 DOUGLAS AVE
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City | ALTAMONTE SPRINGS
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State | FL
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Zip | 32714-2555
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Country | US
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Telephone | 407-389-1195
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Fax | 407-774-4911
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Provider Business Mailing Address
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Address Line | 679 DOUGLAS AVE
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City | ALTAMONTE SPRINGS
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State | FL
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Zip | 32714-2555
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Country | US
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Telephone | 407-389-1195
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Fax | 407-774-4911
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Authorized Official
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Title or Position | PRESIDENT
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Name | RUSSELL M GRAHAM
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Credential | MD
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Telephone | 407-389-1195
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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