Provider Demographics
NPI:1598755605
Name:GRIFFIN FACULTY PHYSICIANS, INC.
Entity type:Organization
Organization Name:GRIFFIN FACULTY PHYSICIANS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DWORKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-732-1508
Mailing Address - Street 1:67 MAPLE AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1328
Mailing Address - Country:US
Mailing Address - Phone:203-732-1330
Mailing Address - Fax:203-732-1332
Practice Address - Street 1:67 MAPLE AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1328
Practice Address - Country:US
Practice Address - Phone:203-732-1330
Practice Address - Fax:203-732-1332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT049045208600000X
208800000X, 363AS0400X, 363LP0200X, 207R00000X, 207RB0002X, 207RC0000X, 207RG0300X, 207VX0000X, 208000000X, 208M00000X, 282N00000X, 363AM0700X
CT003450363LA2200X
CT034350208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No282N00000XHospitalsGeneral Acute Care HospitalGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02057Medicare UPIN