Provider Demographics
NPI:1033103494
Name:GRIFFIN, CHARLES S (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11661 RIVERWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-8901
Mailing Address - Country:US
Mailing Address - Phone:440-286-8885
Mailing Address - Fax:
Practice Address - Street 1:34501 AURORA RD
Practice Address - Street 2:SUITE 206
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-3873
Practice Address - Country:US
Practice Address - Phone:440-248-4636
Practice Address - Fax:440-248-0133
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35040897208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0340312Medicaid
351335OtherWELLCARE
000000126656OtherANTHEM BCBS
340897OtherSUMMACARE
341050418032OtherCARESOURCE
000000126656OtherANTHEM BCBS