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General NPI Number Information
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NPI Number | 1891852653
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Entity Type | Organization
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Legal Business Name | GRAVES DERMA CARE CENTER, PC
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Dates
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Enumeration Date | 01/02/2007
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Last Update Date | 05/20/2008
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Provider Practice Location Address
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Address Line | 601 WALNUT ST SUITE L90
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City | PHILADELPHIA
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State | PA
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Zip | 19106-3304
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Country | US
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Telephone | 215-238-1622
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Fax | 215-238-1944
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Provider Business Mailing Address
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Address Line | 601 WALNUT ST SUITE L90
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City | PHILADELPHIA
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State | PA
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Zip | 19106-3304
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Country | US
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Telephone | 215-238-1622
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Fax | 215-238-1944
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Authorized Official
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Title or Position | CEO PRESIDENT
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Name | DR. VAUGHAN CHANNING GRAVES
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Credential | M.D.
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Telephone | 215-879-2389
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | MD 028158E
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License Number State | PA
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