Provider Demographics
NPI:1902894934
Name:GRIESBAUM, ROBERT V (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:V
Last Name:GRIESBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12700 SOUTHFORK RD
Mailing Address - Street 2:STE 270
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3201
Mailing Address - Country:US
Mailing Address - Phone:314-892-6565
Mailing Address - Fax:314-892-4828
Practice Address - Street 1:12700 SOUTHFORK RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3201
Practice Address - Country:US
Practice Address - Phone:314-892-6565
Practice Address - Fax:314-892-4828
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7958207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201142817Medicaid
MOA12756Medicare UPIN
MO201142817Medicaid