Basic Information
| Provider Information | |||||||||
| NPI: | 1093767303 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 203 N WASHINGTON ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992010254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094448888 | ||||||||
| FaxNumber: | 5094447806 | ||||||||
| Practice Location | |||||||||
| Address1: | 914 W CARLISLE AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 99205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094448888 | ||||||||
| FaxNumber: | 5094447806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 07/02/2019 | ||||||||
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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 | 207R00000X | OP00001872 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8350118 | 05 | WA | MEDICAID |