MEDICARE: SAMUEL TODD GRIFFIN

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1841992039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL TODD GRIFFIN

Provider Business Mailing Address
First Line	:	2017 S GRAND BLVD APT 305
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-1512
Country	:	US
Telephone Number	:	618-980-5658
Fax Number	:

Provider Business Practice Location Address
First Line	:	231 ALBERT SABIN WAY
Second Line	:	ML 515
City	:	CINCINNATI
State	:	OH
Zip	:	45267-0515
Country	:	US
Telephone Number	:	513-558-5387
Fax Number	:

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

Provider Enumeration Date	:	03/20/2023
Last Update Date	:	03/22/2023

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