Provider Demographics
NPI:1295990059
Name:GRIESEMER, MARK VINCENT (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:VINCENT
Last Name:GRIESEMER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 504274
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-4274
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-2115
Practice Address - Fax:417-820-5344
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2010015027207P00000X
OH34009455207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1295990059Medicaid
AR206362003Medicaid
MO440552485OtherTRICARE
MO132680472Medicare PIN
MO500410023Medicare PIN