1124024310 NPI number — DR. EUGENE RAWSON GRIFFIN III MD

Table of content: DR. EUGENE RAWSON GRIFFIN III MD (NPI 1124024310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124024310 NPI number — DR. EUGENE RAWSON GRIFFIN III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIFFIN
Provider First Name:
EUGENE
Provider Middle Name:
RAWSON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124024310
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 17577
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32245-7577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-399-1623
Provider Business Mailing Address Fax Number:
904-399-1624

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3627 UNIVERSITY BLVD S
Provider Second Line Business Practice Location Address:
STE 615
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-7401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-399-1623
Provider Business Practice Location Address Fax Number:
904-399-1624
Provider Enumeration Date:
06/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X , with the licence number:  ME45932 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 160053365 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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