Healthcare Provider Details

I. General information

NPI: 1932199965
Provider Name (Legal Business Name): GLENN CHARLES GRIFFITHS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8225 LAKE ST
BEAR LAKE MI
49614-9612
US

IV. Provider business mailing address

6227 FRANKFORT HWY
BENZONIA MI
49616-8632
US

V. Phone/Fax

Practice location:
  • Phone: 231-864-3314
  • Fax:
Mailing address:
  • Phone: 231-882-9661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39606
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301091466
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: