Basic Information
| Provider Information | |||||||||
| NPI: | 1134228547 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAVES | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6169 JOG ROAD | ||||||||
| Address2: | SUITE A-11 | ||||||||
| City: | LAKE WORTTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614320111 | ||||||||
| FaxNumber: | 5614321075 | ||||||||
| Practice Location | |||||||||
| Address1: | 6169 JOG ROAD | ||||||||
| Address2: | SUITE A-11 | ||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614320111 | ||||||||
| FaxNumber: | 5614321075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT13253 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2110940 | 01 | FL | AETNA-HMO | OTHER | 299647 | 01 | FL | AVMED | OTHER | 214986 | 01 | FL | AMERIGROUP | OTHER | 5170699 | 01 | FL | AETNA-PPO | OTHER | 10746783 | 01 | FL | CAQH | OTHER |