MEDICARE: DR. TIMOTHY P DOMER D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207X00000X	Orthopaedic Surgery Physician	34005918D	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417918111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY P DOMER D.O.

Provider Business Mailing Address
First Line	:	16687 SAINT CLAIR AVE
Second Line	:	SUITE 101
City	:	EAST LIVERPOOL
State	:	OH
Zip	:	43920-9401
Country	:	US
Telephone Number	:	330-385-4610
Fax Number	:	330-385-4620

Provider Business Practice Location Address
First Line	:	16687 SAINT CLAIR AVE
Second Line	:	SUITE 101
City	:	EAST LIVERPOOL
State	:	OH
Zip	:	43920-9401
Country	:	US
Telephone Number	:	330-385-4610
Fax Number	:	330-385-4620

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	10/18/2011

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Directions to “ DR. TIMOTHY P DOMER D.O.” Practice Location

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