MEDICARE: DR. TIM J NICE M.D.

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	174400000X	Specialist	35036891	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	34136753400	OTHER	OH	TAX ID
2	35036891	OTHER	OH	OHIO LICENSE

General Provider Information

NPI Number	:	1457442824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIM J NICE M.D.

Provider Business Mailing Address
First Line	:	34600 CHARDON RD
Second Line	:	SUITE 9
City	:	WILLOUGHBY HILLS
State	:	OH
Zip	:	44094-8480
Country	:	US
Telephone Number	:	440-585-5258
Fax Number	:	440-944-5278

Provider Business Practice Location Address
First Line	:	34600 CHARDON RD
Second Line	:	SUITE 9
City	:	WILLOUGHBY HILLS
State	:	OH
Zip	:	44094-8480
Country	:	US
Telephone Number	:	440-585-5258
Fax Number	:	440-944-5278

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

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	06/16/2010

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