Provider Demographics
NPI:1972232536
Name:GRIFFON, REBECCA (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:GRIFFON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 HOMER ADAMS PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002
Mailing Address - Country:US
Mailing Address - Phone:618-463-3505
Mailing Address - Fax:
Practice Address - Street 1:#4 MEMORIAL DRIVE
Practice Address - Street 2:MEDICAL OFFICE BLDG. B, SUITE 115
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6705
Practice Address - Country:US
Practice Address - Phone:618-741-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-08
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.080683390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program