Healthcare Provider Details

I. General information

NPI: 1467781633
Provider Name (Legal Business Name): TIMOTHY JAMES NIEDER C.PED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2009
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL SUITE 6A
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

3651 CINNAMON TREE LN
SAINT LOUIS MO
63129-2251
US

V. Phone/Fax

Practice location:
  • Phone: 314-747-2545
  • Fax:
Mailing address:
  • Phone: 314-600-8237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberCPED2590
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: