Basic Information
| Provider Information | |||||||||
| NPI: | 1598793754 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIEBEL | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9601 BAPTIST HEALTH DRIVE | ||||||||
| Address2: | MED TOWERS 1, SUITE 900 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012241135 | ||||||||
| FaxNumber: | 5012241253 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 EXCHANGE AVE | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720327824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5015852000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | C6414 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 110817001 | 05 | AR | MEDICAID |