1720274327 NPI number — DR. JAMES WALLACE GRIFFIN JR. MD

Table of content: DR. JAMES WALLACE GRIFFIN JR. MD (NPI 1720274327)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720274327 NPI number — DR. JAMES WALLACE GRIFFIN JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRIFFIN
Provider First Name:
JAMES
Provider Middle Name:
WALLACE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
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:
1720274327
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1729
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39403-1729
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-545-3700
Provider Business Mailing Address Fax Number:
601-450-2493

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW AUGUSTA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39462-0349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-964-8391
Provider Business Practice Location Address Fax Number:
601-964-8393
Provider Enumeration Date:
09/18/2007

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: 207Q00000X , with the licence number:  19990 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11803908 . This is a "CAQH ID NUMBER" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 9493388P02 . This is a "CIGNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 03300361 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9982123 . This is a "AETNA" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: NEW AUGUSTA -1149002 . This is a "WINDSOR HEALTH GROUP" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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