Provider Demographics
NPI:1215943345
Name:GREMMELS, JEFFREY M (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:M
Last Name:GREMMELS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:70 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-4928
Mailing Address - Country:US
Mailing Address - Phone:573-334-6071
Mailing Address - Fax:573-334-4739
Practice Address - Street 1:70 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-4928
Practice Address - Country:US
Practice Address - Phone:573-334-6071
Practice Address - Fax:573-334-4739
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20030253432085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208764100Medicaid
430954380CAPOtherMERCY HEALTH PLAN
IL036-112519OtherIL BLUE CROSS BLUE SHIELD
063896OtherHEALTH ALLIANCE
MO185214OtherMO BLUE CROSS BLUE SHIELD
685169OtherHEALTHLINK
MO185214OtherMO BLUE CROSS BLUE SHIELD
MOP00168121Medicare ID - Type UnspecifiedMO RAILROAD MEDICARE
063896OtherHEALTH ALLIANCE
685169OtherHEALTHLINK
MO208764100Medicaid