Provider Demographics
NPI:1174995724
Name:GRAUSAM, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:GRAUSAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 GRAYDON AVE
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-4323
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1721 GRAYDON AVE
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4323
Practice Address - Country:US
Practice Address - Phone:218-232-2481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer