Healthcare Provider Details

I. General information

NPI: 1194769166
Provider Name (Legal Business Name): DAVID L PRIEBE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 04/18/2022
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3986 MARYVILLE RD
GRANITE CITY IL
62040-4191
US

IV. Provider business mailing address

3986 MARYVILLE RD
GRANITE CITY IL
62040-4191
US

V. Phone/Fax

Practice location:
  • Phone: 618-797-0618
  • Fax: 618-797-2243
Mailing address:
  • Phone: 618-797-0618
  • Fax: 618-797-2243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number66430
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: