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General NPI Number Information
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NPI Number | 1972028421
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Entity Type | Individual
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Provider Name | TIMOTHY RAYMOND NIEDZIELAK DO
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Gender | Male
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Dates
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Enumeration Date | 08/06/2017
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Last Update Date | 09/12/2023
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Provider Practice Location Address
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Address Line | 8201 E RIVERSIDE BLVD
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City | ROCKFORD
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State | IL
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Zip | 61114-2300
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Country | US
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Telephone | 815-971-7000
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Fax | 815-968-7830
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Provider Business Mailing Address
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Address Line | 8201 E RIVERSIDE BLVD
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City | ROCKFORD
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State | IL
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Zip | 61114-2300
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Country | US
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Telephone | 815-971-7000
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Fax | 815-968-7830
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 5665
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 2022018519
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License Number State | MO
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Taxonomy #3
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Taxonomy Code | 207XX0801X
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Taxonomy Name | Orthopaedic Trauma Physician
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License Number | 2022018519
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License Number State | MO
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Taxonomy #4
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 5665
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License Number State | FL
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Taxonomy #5
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 036165587
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License Number State | IL
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