Provider Demographics
NPI:1811971237
Name:GRIESHOP, THEODORE JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOSEPH
Last Name:GRIESHOP
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 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:853 N CHURCH ST
Practice Address - Street 2:STE 720B
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6928
Practice Address - Fax:864-560-4413
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100253207RI0200X
SC14907207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC149075Medicaid
MO203379219Medicaid
MOF25939OtherINDIVIDUAL
P00448178OtherRR MEDICARE
SCAA20345019Medicare PIN
MO203379219Medicaid
MO001013845Medicare ID - Type UnspecifiedINDIVIDUAL
SCAA20343365Medicare PIN