Individual
GLENN E. GRAVES
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
4600 W LOOMIS RD STE 310, GREENFIELD, WI 53220-4858
(414) 281-0963
(414) 281-0959
Mailing address
6020 S PACKARD AVE, CUDAHY, WI 53110-3028
(414) 294-4660
(414) 281-0959
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
27890-020
WI
207WX0009X
Glaucoma Specialist (Ophthalmology) Physician
Primary
27890-020
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0800065
PRIMECARE
WI
01
—
180020621
RR MEDICARE
WI
05
—
31485900
—
WI
01
—
391484998
TAX ID
WI
01
—
391484998011
BLUE CROSS
WI
01
—
391484998C
HUMANA
WI
Enumeration date
10/05/2005
Last updated
04/23/2024
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