Healthcare Provider Details

I. General information

NPI: 1396904637
Provider Name (Legal Business Name): MARILYN GRIFFIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 05/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 W. ROOSEVELT RD
CHICAGO IL
60608
US

IV. Provider business mailing address

1747 W. ROOSEVELT RD
CHICAGO IL
60608
US

V. Phone/Fax

Practice location:
  • Phone: 815-395-5870
  • Fax: 815-395-5750
Mailing address:
  • Phone: 312-996-7723
  • Fax: 815-395-5750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036128792
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: