Individual
CORY E NIEDFELDT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
1712 STUMPF BLVD, TERRYTOWN, LA 70056-3923
(504) 365-1020
(504) 365-1080
Mailing address
625 KENMOOR AVE SE STE 100, GRAND RAPIDS, MI 49546-2395
(616) 356-5000
(616) 356-5001
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
01779
LA
225100000X
Physical Therapist
070013292
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1619980
BCBS OF IL
IL
01
—
567700
MEDICARE GROUP NUMBER
IL
01
—
568080
MEDICARE GROUP NUMBER
IL
01
—
568150
MEDICARE GROUP NUMBER
IN
Enumeration date
09/06/2007
Last updated
03/22/2023
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