Provider Demographics
NPI:1114196375
Name:GIESEKING, JON RICHMOND
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:RICHMOND
Last Name:GIESEKING
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:PO BOX 457
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-0457
Mailing Address - Country:US
Mailing Address - Phone:847-577-8811
Mailing Address - Fax:847-577-3518
Practice Address - Street 1:208 N 2ND ST
Practice Address - Street 2:
Practice Address - City:ALTAMONT
Practice Address - State:IL
Practice Address - Zip Code:62411-1402
Practice Address - Country:US
Practice Address - Phone:618-483-6821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-21
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL510601341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL371199058002Medicaid
IL216029Medicare PIN