MEDICARE: DR. JAMES WALLACE GRIFFIN JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	19990	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11803908	OTHER	MS	CAQH ID NUMBER
2	9493388P02	OTHER	MS	CIGNA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	9982123	OTHER	MS	AETNA
5	NEW AUGUSTA -1149002	OTHER	MS	WINDSOR HEALTH GROUP

General Provider Information

NPI Number	:	1720274327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMES WALLACE GRIFFIN JR. MD

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

Provider Business Practice Location Address
First Line	:	404 MAIN STREET
Second Line	:
City	:	NEW AUGUSTA
State	:	MS
Zip	:	39462-0349
Country	:	US
Telephone Number	:	601-964-8391
Fax Number	:	601-964-8393

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2007
Last Update Date	:	01/17/2020

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