Provider Demographics
NPI:1174719264
Name:GRIFFITH, MICHAEL G
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:GRIFFITH
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 1:200 W DOUGLAS AVE
Mailing Address - Street 2:STE. 1040
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3013
Mailing Address - Country:US
Mailing Address - Phone:316-263-0003
Mailing Address - Fax:316-263-1241
Practice Address - Street 1:2033 W HOUSTON ST
Practice Address - Street 2:STE. A
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8304
Practice Address - Country:US
Practice Address - Phone:918-259-0374
Practice Address - Fax:918-259-0376
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK700421Medicare PIN