Provider Demographics
NPI:1851551907
Name:GRIESEMER, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:GRIESEMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5044
Mailing Address - Country:US
Mailing Address - Phone:573-683-2327
Mailing Address - Fax:
Practice Address - Street 1:1403 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:MO
Practice Address - Zip Code:63834
Practice Address - Country:US
Practice Address - Phone:573-683-2327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2011-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011002939207Q00000X
IL125054803390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program