Healthcare Provider Details

I. General information

NPI: 1114904539
Provider Name (Legal Business Name): MATTHEW GREGORY NIEMI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 PINE ST
LANGLEY AFB VA
23665-2025
US

IV. Provider business mailing address

9802 RIVER RD
NEWPORT NEWS VA
23601-4211
US

V. Phone/Fax

Practice location:
  • Phone: 757-764-9767
  • Fax:
Mailing address:
  • Phone: 757-926-4356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01054815A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101239451
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036176261
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: