Provider Demographics
NPI:1114097474
Name:JOHN NIEMELA
Entity Type:Organization
Organization Name:JOHN NIEMELA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:NIEMELA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:906-225-0181
Mailing Address - Street 1:1015 N 3RD STREET
Mailing Address - Street 2:STE 6
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-3500
Mailing Address - Country:US
Mailing Address - Phone:906-225-0181
Mailing Address - Fax:906-225-0340
Practice Address - Street 1:1015 N 3RD ST
Practice Address - Street 2:SUITE #6
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-3500
Practice Address - Country:US
Practice Address - Phone:906-225-0181
Practice Address - Fax:906-225-0340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002208213E00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4855201230OtherBCBSM
MI611477200OtherUS DEPARTMENT OF LABOR
MIP00314266OtherRAILROAD MEDICARE
MI134882948Medicaid
MI5901002208OtherLICENSE
MI4882948OtherUPPER PENINSULA HLTH PLAN
MI510E210880OtherBCBSM ORTHOTIST
MI611477200OtherUS DEPARTMENT OF LABOR
MIP00314266OtherRAILROAD MEDICARE
MI0P31830Medicare PIN