Basic Information
| Provider Information | |||||||||
| NPI: | 1205831666 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | BOBBY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1227 N STATE ST | ||||||||
| Address2: | STE 101 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013552485 | ||||||||
| FaxNumber: | 6013531463 | ||||||||
| Practice Location | |||||||||
| Address1: | 2969 CURRAN DR N | ||||||||
| Address2: | STE 200 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019745600 | ||||||||
| FaxNumber: | 6019745699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2005 | ||||||||
| LastUpdateDate: | 04/27/2017 | ||||||||
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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 | 207RH0003X | 10277 | MS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0002X | 10277 | MS | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4225962 | 01 | AETNA HEALTHCARE | OTHER | 1966452 | 05 | LA | MEDICAID | 00115226 | 05 | MS | MEDICAID |