Provider Demographics
NPI:1275293599
Name:PIONEER MONONGALIA MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:PIONEER MONONGALIA MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-779-6303
Mailing Address - Street 1:13067 N TELECOM PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13067 N TELECOM PKWY
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33637-0926
Practice Address - Country:US
Practice Address - Phone:813-779-6303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
123456789OtherINTERNAL MEDICINE