Basic Information
| Provider Information | |||||||||
| NPI: | 1164765582 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAVES | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 S 2ND ST | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720062309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
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| Practice Location | |||||||||
| Address1: | 120 N 4TH ST | ||||||||
| Address2: | |||||||||
| City: | BARLOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420249579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703343131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2013 | ||||||||
| LastUpdateDate: | 06/16/2016 | ||||||||
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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 | 207Q00000X | R2853 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 03661 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100284330 | 05 | KY | MEDICAID |