Basic Information
| Provider Information | |||||||||
| NPI: | 1861704140 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEELY | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7590 AUBURN ROAD, SUITE 014 | ||||||||
| Address2: | ATTN: MED STAFF | ||||||||
| City: | CONCORD TWP. | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440779176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403541899 | ||||||||
| FaxNumber: | 4403541845 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | CHARDON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440241076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402791500 | ||||||||
| FaxNumber: | 4402791501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2010 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35-010467 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0085189 | 05 | OH | MEDICAID |