GRIESEMER CHIROPRACTIC, LLC

Provider Demographics

• NPI: 1598953317
• Name: GRIESEMER CHIROPRACTIC, LLC
• Entity Type: Organization
• Organization Name: GRIESEMER CHIROPRACTIC, LLC
• Other - Org Name: GREENWOOD PAIN MANAGEMENT
• Other - Org Type: Doing Business As
• Authorized Official - Title/Position: DOCTOR, MEMBER, MANAGER
• Authorized Official - Prefix: DR
• Authorized Official - First Name: MARK
• Authorized Official - Middle Name: THOMAS
• Authorized Official - Last Name: GRIESEMER
• Authorized Official - Credentials: DC
• Authorized Official - Phone: 317-884-4400
• Mailing Address - Street 1: 223 S STATE ROAD 135
• Mailing Address - City: GREENWOOD
• Mailing Address - State: IN
• Mailing Address - Zip Code: 46142-1421
• Mailing Address - Country: US
• Mailing Address - Phone: 317-881-9792
• Mailing Address - Fax: 317-882-1766
• Practice Address - Street 1: 223 S STATE ROAD 135
• Practice Address - City: GREENWOOD
• Practice Address - State: IN
• Practice Address - Zip Code: 46142-1421
• Practice Address - Country: US
• Practice Address - Phone: 317-881-9792
• Practice Address - Fax: 317-882-1766
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2007-10-05
• Last Update Date: 2017-07-26

Provider Licenses

State	License ID	Taxonomies
IN	08001713	111N00000X
IN	01068922A	207Q00000X
IN	01053184A	208VP0014X
		261QM1300X
IN	10000648A	363A00000X
IN	10002090A	363AM0700X
IN	71005986A	363LF0000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	208VP0014X	Allopathic & Osteopathic Physicians	Pain Medicine	Interventional Pain Medicine	Group - Multi-Specialty
No	111N00000X	Chiropractic Providers	Chiropractor		Group - Multi-Specialty
No	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Multi-Specialty
No	261QM1300X	Ambulatory Health Care Facilities	Clinic/Center	Multi-Specialty	Group - Multi-Specialty
No	363A00000X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant		Group - Multi-Specialty
No	363AM0700X	Physician Assistants & Advanced Practice Nursing Providers	Physician Assistant	Medical	Group - Multi-Specialty
No	363LF0000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner	Family	Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IN	000000207597	Other	ANTHEM
IN	200223900	Medicaid
	350053496	Other	RAILROAD MEDICARE
	7165004	Other	AETNA
IN	08001713	Other	LICENSE
	186630	Medicare PIN
	7165004	Other	AETNA
	350053496	Other	RAILROAD MEDICARE
	350053496	Other	RAILROAD MEDICARE