MEDICARE: ADAM W GRAHAM P.A.

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	363A00000X	Physician Assistant	5703835-1206	UT
2	363AM0700X	Medical Physician Assistant	5703835-1206	UT
3	363AM0700X	Medical Physician Assistant	MT 503	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	80105	OTHER	PEHP #
2	224848	OTHER	ALTIUS #
3	13228	OTHER	UNIVERSITY HEALTH PLANS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811947344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADAM W GRAHAM P.A.

Provider Business Mailing Address
First Line	:	12499 CLAIMSTAKE CT
Second Line	:
City	:	LOLO
State	:	MT
Zip	:	59847-9435
Country	:	US
Telephone Number	:	406-493-8269
Fax Number	:

Provider Business Practice Location Address
First Line	:	12499 CLAIMSTAKE CT
Second Line	:
City	:	LOLO
State	:	MT
Zip	:	59847-9435
Country	:	US
Telephone Number	:	406-493-8269
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	08/19/2010

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Directions to “ ADAM W GRAHAM P.A.” Practice Location

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