Basic Information
| Provider Information | |||||||||
| NPI: | 1700878329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STRIEBEL | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | HENRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3371 KEMP RD | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454312514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374584200 | ||||||||
| FaxNumber: | 9374584209 | ||||||||
| Practice Location | |||||||||
| Address1: | 3371 KEMP RD | ||||||||
| Address2: | |||||||||
| City: | BEAVERCREEK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454312514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374584200 | ||||||||
| FaxNumber: | 9374584209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02003471A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 34-00-4194-S | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200939240 | 05 | IN | MEDICAID | 000000731793 | 01 | IN | ANTHEM | OTHER | 0659023 | 05 | OH | MEDICAID |