Basic Information
Provider Information | |||||||||
NPI: | 1568535003 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRAHAM | ||||||||
FirstName: | SARA | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5400 FRANTZ RD | ||||||||
Address2: | STE 250 | ||||||||
City: | DUBLIN | ||||||||
State: | OH | ||||||||
PostalCode: | 430164144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6145446161 | ||||||||
FaxNumber: | 6145661901 | ||||||||
Practice Location | |||||||||
Address1: | 1200 SYCAMORE LINE | ||||||||
Address2: |   | ||||||||
City: | SANDUSKY | ||||||||
State: | OH | ||||||||
PostalCode: | 448704029 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4196255269 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2006 | ||||||||
LastUpdateDate: | 01/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 34009679 | OH | N |   | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207QH0002X | 34.009679 | OH | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
ID Information
ID | Type | State | Issuer | Description | 3037725 | 05 | OH |   | MEDICAID |