Basic Information
| Provider Information | |||||||||
| NPI: | 1205801347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100186 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761850186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177317771 | ||||||||
| FaxNumber: | 8177317774 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761044917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177021166 | ||||||||
| FaxNumber: | 8177021405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | F1600 | TX | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VM0101X | F1600 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8H3360 | 01 | TX | BCBS | OTHER | 139366218 | 05 | TX | MEDICAID | 139366223 | 05 | TX | MEDICAID | 4227216 | 01 | TX | AETNA | OTHER | 139366219 | 05 | TX | MEDICAID | 10028874 | 01 | TX | AMERIGROUP | OTHER |