=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679696793
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRAHAM LEE ROBERTS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2007
-----------------------------------------------------
Last Update Date | 07/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 TYSON AVE
-----------------------------------------------------
City | PARIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38242-4544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-644-8379
-----------------------------------------------------
Fax | 731-644-8488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1878 SWYNFORD LN
-----------------------------------------------------
City | COLLIERVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38017-7858
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-221-8554
-----------------------------------------------------
Fax | 731-644-8488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 39754
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 37353
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------