Provider Demographics
NPI:1700071321
Name:NIEDFELDT, CORY E (PT)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:E
Last Name:NIEDFELDT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 KENMOOR AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2395
Mailing Address - Country:US
Mailing Address - Phone:616-356-5000
Mailing Address - Fax:616-356-5001
Practice Address - Street 1:1712 STUMPF BLVD
Practice Address - Street 2:
Practice Address - City:TERRYTOWN
Practice Address - State:LA
Practice Address - Zip Code:70056-3923
Practice Address - Country:US
Practice Address - Phone:504-365-1020
Practice Address - Fax:504-365-1080
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013292225100000X
LA01779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL568080OtherMEDICARE GROUP NUMBER
IL567700OtherMEDICARE GROUP NUMBER
IN568150OtherMEDICARE GROUP NUMBER
IL1619980OtherBCBS OF IL
ILK51660Medicare PIN
IL1619980OtherBCBS OF IL
ILK51662Medicare PIN