Provider Demographics
NPI:1053161588
Name:GRIFFIN, SAMUEL ELIAS
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ELIAS
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1808 COUNTY ROAD 18
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IN
Mailing Address - Zip Code:46793-9474
Mailing Address - Country:US
Mailing Address - Phone:260-573-8334
Mailing Address - Fax:
Practice Address - Street 1:1100 REID PKWY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1157
Practice Address - Country:US
Practice Address - Phone:765-935-8988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-26
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program