Basic Information
| Provider Information | |||||||||
| NPI: | 1780647891 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRIEBEL | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6005 DEPT 196 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462066005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662827905 | ||||||||
| FaxNumber: | 8007310751 | ||||||||
| Practice Location | |||||||||
| Address1: | 3503 S REED RD | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469023838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3176149817 | ||||||||
| FaxNumber: | 3176149655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 02/21/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 01033765A | IN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100068610 | 05 | IN | MEDICAID |