Healthcare Provider Details

I. General information

NPI: 1235355702
Provider Name (Legal Business Name): MATTHEW R GRIGGS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 06/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 CHANNING WAY
IDAHO FALLS ID
83404-7533
US

IV. Provider business mailing address

3100 CHANNING WAY P.O. BOX 1647
IDAHO FALLS ID
83404-7533
US

V. Phone/Fax

Practice location:
  • Phone: 208-535-4130
  • Fax: 208-535-4125
Mailing address:
  • Phone: 208-535-4130
  • Fax: 208-535-4125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberM-9888
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberM9888
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: