Basic Information
| Provider Information | |||||||||
| NPI: | 1285669739 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAVES | ||||||||
| FirstName: | ANITRA | ||||||||
| MiddleName: | SIMONE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 REINHARDT COLLEGE PKWY | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301145257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784932527 | ||||||||
| FaxNumber: | 6784935608 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 REINHARDT COLLEGE PKWY | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | CANTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301145257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784932527 | ||||||||
| FaxNumber: | 6784925608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 49799 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RC0200X | 049799 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RC0200X | 01078528A | IN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RS0012X | 49799 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine | 207RP1001X | 049799 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 289374423A | 05 | GA | MEDICAID |