Basic Information
| Provider Information | |||||||||
| NPI: | 1730193756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRAHAM | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | DIANE | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRAHAM | ||||||||
| OtherFirstName: | SUSAN | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 17752 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802170752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 THREE SPRINGS BLVD | ||||||||
| Address2: | |||||||||
| City: | DURANGO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813018296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 03/24/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 35621 | CO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 35621 | CO | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00315470 | 01 | CO | RAILROAD MEDICARE PIN | OTHER | 01356211 | 05 | CO | MEDICAID | 000L3404 | 05 | NM | MEDICAID |