Provider Demographics
NPI:1750421640
Name:GRIESEMER, BERNARD A (MD)
Entity type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:A
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:4331 S FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-7328
Practice Address - Country:US
Practice Address - Phone:417-820-5000
Practice Address - Fax:417-820-5025
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6866207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR82172OtherARK BLUE SHIELD
MO13118OtherMO BLUE SHIELD
MO200254837Medicaid
E59576Medicare UPIN
MO200254837Medicaid