Provider Demographics
NPI:1649476680
Name:GRIFFIN, MANDI TINE (MD)
Entity type:Individual
Prefix:
First Name:MANDI
Middle Name:TINE
Last Name:GRIFFIN
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 1:1224 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2338
Mailing Address - Country:US
Mailing Address - Phone:406-375-4823
Mailing Address - Fax:406-375-4846
Practice Address - Street 1:1200 WESTWOOD DR
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2345
Practice Address - Country:US
Practice Address - Phone:406-363-5101
Practice Address - Fax:406-363-7652
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT12237207Q00000X
COTL-2558207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1649476680Medicaid
ID1649476680Medicaid
ID1649476680Medicaid
MT011004319, BPCMedicare PIN