Healthcare Provider Details

I. General information

NPI: 1083618847
Provider Name (Legal Business Name): CHARLES W GRIFFIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 03/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 US HWY 41 N
TIFTON GA
31794
US

IV. Provider business mailing address

2225 US HWY 41 N
TIFTON GA
31794
US

V. Phone/Fax

Practice location:
  • Phone: 229-391-4100
  • Fax:
Mailing address:
  • Phone: 229-391-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number35428
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: