Basic Information
| Provider Information | |||||||||
| NPI: | 1932209434 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | TIMOTHY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13008 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173646253 | ||||||||
| FaxNumber: | 5173646204 | ||||||||
| Practice Location | |||||||||
| Address1: | 13191 SCHAVEY RD | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | DEWITT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488209036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176699109 | ||||||||
| FaxNumber: | 5176699839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2006 | ||||||||
| LastUpdateDate: | 09/19/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301072888 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0801900442 | 01 | MI | BCBS INDIVIDUAL PIN | OTHER | 4309145 | 05 | MI | MEDICAID |