Healthcare Provider Details

I. General information

NPI: 1801826235
Provider Name (Legal Business Name): M ALLAN GRIFFITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 04/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 EAST COLLEGE AVE
BLOOMINGTON IL
61701
US

IV. Provider business mailing address

602 W UNIVERSITY AVE
URBANA IL
61801-2530
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-3000
  • Fax:
Mailing address:
  • Phone: 217-383-3311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036051930
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number036051930
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036051930
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: