Healthcare Provider Details

I. General information

NPI: 1851551907
Provider Name (Legal Business Name): JEFFREY GRIESEMER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 10/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 E MARSHALL ST
CHARLESTON MO
63834
US

IV. Provider business mailing address

1008 N MAIN ST
SIKESTON MO
63801-5044
US

V. Phone/Fax

Practice location:
  • Phone: 573-683-2327
  • Fax:
Mailing address:
  • Phone: 573-683-2327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2011002939
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125054803
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: