Provider Demographics
NPI:1871692582
Name:STANLEY C GRAVES M D PC
Entity type:Organization
Organization Name:STANLEY C GRAVES M D PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:CECIL
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:602-952-8111
Mailing Address - Street 1:3104 E CAMELBACK RD # 1003
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4502
Mailing Address - Country:US
Mailing Address - Phone:602-952-8111
Mailing Address - Fax:602-952-1572
Practice Address - Street 1:5080 N 40TH ST STE 103
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2158
Practice Address - Country:US
Practice Address - Phone:602-952-8111
Practice Address - Fax:602-952-1572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22387174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ74956Medicare PIN
AZA97912Medicare UPIN