Individual
MR. GLEN ROBERT GRAVES
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
2500 N STATE ST, JACKSON, MS 39216-4500
(601) 815-7100
Mailing address
2500 N STATE ST, JACKSON, MS 39216-4500
(601) 815-7100
Taxonomy
Speciality
Code
Description
License number
State
2080N0001X
Neonatal-Perinatal Medicine Physician
Primary
05989
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00017226
—
MS
05
—
1969265
—
LA
Enumeration date
06/27/2006
Last updated
06/27/2012
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