Provider Demographics
NPI:1447451349
Name:GRAEBER, ANGELA (MD)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:GRAEBER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216
Mailing Address - Country:US
Mailing Address - Phone:601-984-2538
Mailing Address - Fax:601-815-1854
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-2538
Practice Address - Fax:601-815-1854
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS113602085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP004622007OtherRAILROAD MEDICARE
MS08603769Medicaid
LA1025429Medicaid
MSP00436435OtherRAILROAD MEDICARE
MSP01168130OtherRR MEDICARE PTAN
AL157418Medicaid
MS08603769Medicaid
MSP00436435OtherRAILROAD MEDICARE
MSE57910Medicare UPIN
LA1025429Medicaid