Healthcare Provider Details

I. General information

NPI: 1235659905
Provider Name (Legal Business Name): LAURA MICHELLE GRIESINGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2017
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N LAFAYETTE BLVD
SOUTH BEND IN
46601-1004
US

IV. Provider business mailing address

530 N LAFAYETTE BLVD
SOUTH BEND IN
46601-1004
US

V. Phone/Fax

Practice location:
  • Phone: 574-234-4176
  • Fax:
Mailing address:
  • Phone: 574-234-4176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301111891
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01087647A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: