MEDICARE: TIMOTHY P. DOMER DO,INC

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

General Provider Information

NPI Number	:	1801946884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIMOTHY P. DOMER DO,INC

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	:	PRESIDENT
Name	:	TIMOTHY P DOMER
Credential	:	DO
Telephone Number	:	330-385-4610

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	08/22/2020

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