=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902880529
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WALTER E GRAHAM MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2005
-----------------------------------------------------
Last Update Date | 09/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1331 NORTH PARK DRIVE
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-359-5330
-----------------------------------------------------
Fax | 281-359-6117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1331 NORTH PARK DRIVE
-----------------------------------------------------
City | KINGWOOD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-359-5330
-----------------------------------------------------
Fax | 281-359-6117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | MD.15564R
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | H4357
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 29172
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | H4357
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | H4357
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------