Basic Information
Provider Information | |||||||||
NPI: | 1295713584 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAHAM | ||||||||
FirstName: | STEVEN | ||||||||
MiddleName: | DONALD | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 550 | ||||||||
Address2: |   | ||||||||
City: | LOWELL | ||||||||
State: | AR | ||||||||
PostalCode: | 727450550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4794637775 | ||||||||
FaxNumber: | 4794637187 | ||||||||
Practice Location | |||||||||
Address1: | 3336 N FUTRALL DRIVE | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 72703 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4794633000 | ||||||||
FaxNumber: | 4794633050 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/06/2006 | ||||||||
LastUpdateDate: | 01/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD0000019275 | TN | N |   | Other Service Providers | Specialist |   | 174400000X | E-13761 | AR | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 3845929 | 05 | TN |   | MEDICAID | 4062895 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER |