Provider Demographics
NPI:1881613727
Name:GRIFFIN, SUSAN R (MD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:R
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:PO BOX 662
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-0662
Mailing Address - Country:US
Mailing Address - Phone:276-228-6499
Mailing Address - Fax:276-228-6145
Practice Address - Street 1:1785 W. LEE HWY
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382
Practice Address - Country:US
Practice Address - Phone:276-228-6499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2017-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20775207P00000X
VA0101045977207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2002838000Medicaid
D04280Medicare UPIN
WV2002838000Medicaid