Basic Information
| Provider Information | |||||||||
| NPI: | 1861480469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BULLARD | ||||||||
| FirstName: | GRAHAM | ||||||||
| MiddleName: | WESLEY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 36351 | ||||||||
| Address2: | SOUTHEAST ANESTHESIOLOGY CONSULTANTS PA | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282366351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043775772 | ||||||||
| FaxNumber: | 7043773389 | ||||||||
| Practice Location | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271575812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 26624 | NC | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 26624 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8919726 | 05 | NC | MEDICAID | N26624 | 05 | SC | MEDICAID |