Basic Information
| Provider Information | |||||||||
| NPI: | 1891837944 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRAHAM WINDHAM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRAHAM WINDHAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PIERREPONT PLZ | ||||||||
| Address2: | SUITE 901 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112012790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125296445 | ||||||||
| FaxNumber: | 2122602147 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 PIERREPONT PLZ | ||||||||
| Address2: | SUITE 901 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112012790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125296445 | ||||||||
| FaxNumber: | 2122602147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 08/16/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEBSTER | ||||||||
| AuthorizedOfficialFirstName: | BASIL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2125296445 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251V00000X | Y | Agencies | Voluntary or Charitable |
ID Information
| ID | Type | State | Issuer | Description | 00327995 | 05 | NY | MEDICAID | 03036775 | 05 | NY | MEDICAID | 00698673 | 05 | NY | MEDICAID | 02997877 | 05 | NY | MEDICAID |