Healthcare Provider Details

I. General information

NPI: 1790753036
Provider Name (Legal Business Name): TIMOTHY ALAN NIEMI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2006
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2662 ELM RD NE
CORTLAND OH
44410-9393
US

IV. Provider business mailing address

2287 STATE ROUTE 305 P. O. BOX 542
CORTLAND OH
44410-9304
US

V. Phone/Fax

Practice location:
  • Phone: 330-841-3004
  • Fax: 330-841-3001
Mailing address:
  • Phone: 330-841-3004
  • Fax: 330-841-3001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35-053422
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: