Provider Demographics
NPI:1003843665
Name:NIEMIEC, TED ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:ROBERT
Last Name:NIEMIEC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3566
Mailing Address - Country:US
Mailing Address - Phone:219-924-7774
Mailing Address - Fax:
Practice Address - Street 1:1726 LAUREL LN
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3566
Practice Address - Country:US
Practice Address - Phone:219-924-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36070247207P00000X, 2083P0500X, 2083S0010X
IN010328042083P0500X, 207P00000X, 2083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine