MEDICARE: JOHN S GRAVES OD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901003143	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	900Z60027	OTHER	MI	BCBS

General Provider Information

NPI Number	:	1801257522
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN S GRAVES OD PC

Provider Business Mailing Address
First Line	:	PO BOX 576
Second Line	:
City	:	STANDISH
State	:	MI
Zip	:	48658-0576
Country	:	US
Telephone Number	:	989-846-4197
Fax Number	:	989-846-4989

Provider Business Practice Location Address
First Line	:	105 N GROVE ST
Second Line	:
City	:	STANDISH
State	:	MI
Zip	:	48658-2508
Country	:	US
Telephone Number	:	989-846-4197
Fax Number	:	989-846-4989

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN S GRAVES
Credential	:	OD
Telephone Number	:	989-846-4197

Provider Enumeration Date	:	03/08/2016
Last Update Date	:	01/05/2017

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