Provider Demographics
NPI:1932353984
Name:GIESE, MARK R
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:R
Last Name:GIESE
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 1:2500 MILTON AVE
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-0452
Mailing Address - Country:US
Mailing Address - Phone:608-754-4746
Mailing Address - Fax:
Practice Address - Street 1:2500 MILTON AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0452
Practice Address - Country:US
Practice Address - Phone:608-754-4746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI704237700000X
ILIDPH0737237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist