Provider Demographics
NPI:1710912399
Name:GRIFFITH, MARK NUTTER (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:NUTTER
Last Name:GRIFFITH
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 1:1225 S. BROADWAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504
Mailing Address - Country:US
Mailing Address - Phone:859-258-4568
Mailing Address - Fax:859-258-4698
Practice Address - Street 1:1000 MON HEALTH MEDICAL PARK DR STE 1102
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505
Practice Address - Country:US
Practice Address - Phone:304-598-2801
Practice Address - Fax:304-599-6463
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV28054207RC0200X, 207RP1001X
KY25206207RC0200X, 207RP1001X
WI65883207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4000501OtherMEDICARE LAB GROUP
KYP00179690OtherRR MEDICARE PIN
KY36000818OtherASC MEDICAID GROUP
KYCB5773OtherRR MEDICARE GROUP
KY37903705OtherMEDICAID LAB GROUP
KY64089907Medicaid
KYASC1019OtherASC MEDICARE GROUP
KY0169Medicare PIN
KYCB5773OtherRR MEDICARE GROUP
KYP00179690OtherRR MEDICARE PIN