Basic Information
| Provider Information | |||||||||
| NPI: | 1992886212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAVES | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 202 | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 691620202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3086412101 | ||||||||
| FaxNumber: | 9703478865 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 POLE CREEK XING | ||||||||
| Address2: | |||||||||
| City: | SIDNEY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 691622901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3082545825 | ||||||||
| FaxNumber: | 9703478865 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 02/14/2017 | ||||||||
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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 | 208800000X | 21510 | NE | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 10025486400 | 05 | NE | MEDICAID | 115539300 | 05 | WY | MEDICAID |