Healthcare Provider Details

I. General information

NPI: 1659402220
Provider Name (Legal Business Name): MARY HOPE GRIFFIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 MEMORIAL DR STE 402
SOUTH BEND IN
46601-1074
US

IV. Provider business mailing address

621 MEMORIAL DR STE 402
SOUTH BEND IN
46601-1074
US

V. Phone/Fax

Practice location:
  • Phone: 574-400-4550
  • Fax: 574-400-4551
Mailing address:
  • Phone: 574-400-4550
  • Fax: 574-400-4551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01066608A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: