Provider Demographics
NPI:1790761252
Name:GRIFFIN, ANDREW TODD (CRNA)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:TODD
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 GRAY CLUB COURT
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1396
Mailing Address - Country:US
Mailing Address - Phone:618-218-0115
Mailing Address - Fax:
Practice Address - Street 1:311 WEST LINCOLN
Practice Address - Street 2:SUITE 300
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1921
Practice Address - Country:US
Practice Address - Phone:618-233-7077
Practice Address - Fax:660-826-4852
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209001330367500000X
IL041269915367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK18788Medicare PIN