Healthcare Provider Details

I. General information

NPI: 1861704140
Provider Name (Legal Business Name): TIMOTHY RICHARD NEELY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2010
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 5TH AVE
CHARDON OH
44024-1076
US

IV. Provider business mailing address

7590 AUBURN ROAD, SUITE 014 ATTN: MED STAFF
CONCORD TWP. OH
44077-9176
US

V. Phone/Fax

Practice location:
  • Phone: 440-279-1500
  • Fax: 440-279-1501
Mailing address:
  • Phone: 440-354-1899
  • Fax: 440-354-1845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-010467
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: