MEDICARE: LISA MARIE GRAVELLE M.D.

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	207V00000X	Obstetrics & Gynecology Physician	5640031-1205	UT

General Provider Information

NPI Number	:	1821028820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARIE GRAVELLE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 27128
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84127-0128
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5063 S COTTONWOOD ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-6766
Country	:	US
Telephone Number	:	801-507-1800
Fax Number	:	801-507-1825

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

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	09/24/2025

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