Basic Information
| Provider Information | |||||||||
| NPI: | 1477536761 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIFFIN | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | JOAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4602 DEPT | ||||||||
| Address2: | |||||||||
| City: | CAROL STREAM | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601220021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062254821 | ||||||||
| FaxNumber: | 9062254537 | ||||||||
| Practice Location | |||||||||
| Address1: | 580 W COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | MARQUETTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498552705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9062257979 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 04/22/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 44008-020 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QB0002X | 4301091765 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | Bariatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1477536761 | 05 | MI | MEDICAID | EG091765 | 01 | MI | BCBS OF MICHIGAN | OTHER |