Basic Information
Provider Information | |||||||||
NPI: | 1699789727 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRIFFIN | ||||||||
FirstName: | DWAYNE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 560 W MITCHELL ST | ||||||||
Address2: | STE 505 | ||||||||
City: | PETOSKEY | ||||||||
State: | MI | ||||||||
PostalCode: | 497702275 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2314872100 | ||||||||
FaxNumber: | 2314876049 | ||||||||
Practice Location | |||||||||
Address1: | 560 W MITCHELL ST | ||||||||
Address2: | SUITE 505 | ||||||||
City: | PETOSKEY | ||||||||
State: | MI | ||||||||
PostalCode: | 497702275 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2314872100 | ||||||||
FaxNumber: | 2314876049 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2006 | ||||||||
LastUpdateDate: | 01/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 5101007674 | MI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 114092379 | 05 | MI |   | MEDICAID | DG007674 | 01 | MI | BS STATE LIC# | OTHER | 295240013 | 01 | MI | BCBSM PIN | OTHER |