Provider Demographics
NPI:1861704140
Name:NEELY, TIMOTHY RICHARD (DO)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RICHARD
Last Name:NEELY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7590 AUBURN ROAD, SUITE 014
Mailing Address - Street 2:ATTN: MED STAFF
Mailing Address - City:CONCORD TWP.
Mailing Address - State:OH
Mailing Address - Zip Code:44077-9176
Mailing Address - Country:US
Mailing Address - Phone:440-354-1899
Mailing Address - Fax:440-354-1845
Practice Address - Street 1:510 5TH AVE
Practice Address - Street 2:
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-1076
Practice Address - Country:US
Practice Address - Phone:440-279-1500
Practice Address - Fax:440-279-1501
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-010467207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0085189Medicaid