Glen Robert Graves, M.D.

Primary specialty

Neonatal-Perinatal Medicine PhysicianTaxonomy code 2080N0001X

License

05989 Issued in MS

Practice address

2500 N State St
Jackson, MS 39216-4500

Phone

(601) 815-7100

NPI assigned

Jun 27, 2006

Last updated

Jun 27, 2012By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1151366400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1340755200000",
    "number": "1407883234",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2500 N STATE ST",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392164500",
            "telephone_number": "601-815-7100"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2500 N STATE ST",
            "city": "JACKSON",
            "state": "MS",
            "postal_code": "392164500",
            "telephone_number": "601-815-7100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "GRAVES",
        "first_name": "GLEN",
        "middle_name": "ROBERT",
        "name_prefix": "Mr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-06-27",
        "last_updated": "2012-06-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2080N0001X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Neonatal-Perinatal Medicine",
            "state": "MS",
            "license": "05989",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1969265",
            "state": "LA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00017226",
            "state": "MS"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Tiffani L Grant, LD
• Scotty W. Grantham, R.P.T.
• Grassroots Therapy Solutions LLC
• Kim L. Gratz, PH.D.
• Mary K Gravel, CRNA
• Lauren Baillie Graves, PH.D.
• Marilyn Davidson Graves, MD
• Matthew L Graves, MD
• Alan Gray, CPNP-AC
• Alvin Gray

• Neonatal-Perinatal Medicine Physician in Jackson, MS
• Providers in Jackson, MS by specialty
• Neonatal-Perinatal Medicine Physician in Mississippi

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 27, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.