Provider Demographics
NPI:1871559690
Name:GRIESEMER, MARK THOMAS (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:THOMAS
Last Name:GRIESEMER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 S STATE ROAD 135
Mailing Address - Street 2:
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 - Street 2:
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
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001713A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN7165004OtherAETNA PIN
IN000000207597OtherANTHEM PIN
IN200223900Medicaid
IN200223900Medicaid
INM400038997Medicare PIN