MEDICARE: DR. TERRENCE M GRAHAM DPM,FACFAS

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	213ES0103X	Foot & Ankle Surgery Podiatrist	016003032	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	480008850	OTHER	IL	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0060215009	OTHER	IL	BCBS
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972585990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TERRENCE M GRAHAM DPM,FACFAS

Provider Business Mailing Address
First Line	:	102 W KENWOOD AVE
Second Line	:	SUITE 150
City	:	DECATUR
State	:	IL
Zip	:	62526-4368
Country	:	US
Telephone Number	:	217-875-3668
Fax Number	:	217-875-4277

Provider Business Practice Location Address
First Line	:	2 MEMORIAL DR STE 305
Second Line	:
City	:	DECATUR
State	:	IL
Zip	:	62526-3999
Country	:	US
Telephone Number	:	217-876-4830
Fax Number	:	217-876-8385

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

Provider Enumeration Date	:	11/16/2005
Last Update Date	:	02/28/2018

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Directions to “ DR. TERRENCE M GRAHAM DPM,FACFAS” Practice Location

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