Provider Demographics
NPI:1174250104
Name:GRAHAM PEDIATRIC CLINIC, LLC
Entity type:Organization
Organization Name:GRAHAM PEDIATRIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-851-7350
Mailing Address - Street 1:706 MAIN ST STE 2A
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-6010
Mailing Address - Country:US
Mailing Address - Phone:541-851-7350
Mailing Address - Fax:541-851-7351
Practice Address - Street 1:706 MAIN ST STE 2A
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-6010
Practice Address - Country:US
Practice Address - Phone:541-591-0877
Practice Address - Fax:888-519-9117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-01
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty