Provider Demographics
NPI:1578688644
Name:GRIFFIN, EDMOND I (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:I
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 1:5555 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 190
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1703
Mailing Address - Country:US
Mailing Address - Phone:404-256-4457
Mailing Address - Fax:404-843-3469
Practice Address - Street 1:5555 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 190
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1703
Practice Address - Country:US
Practice Address - Phone:404-256-4457
Practice Address - Fax:404-843-3469
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014914174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD40024Medicare UPIN