1154343911 NPI number — GARY V. SNYDER O.D.

Table of content: (NPI 1578270930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154343911 NPI number — GARY V. SNYDER O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SNYDER
Provider First Name:
GARY
Provider Middle Name:
V.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154343911
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1002 LEXINGTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GEORGETOWN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40324-1463
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-868-0422
Provider Business Mailing Address Fax Number:
502-867-1967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 LEXINGTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40324-1463
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-868-0422
Provider Business Practice Location Address Fax Number:
502-867-1967
Provider Enumeration Date:
07/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0988DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 37903705 . This is a "MEDICAID LAB GROUP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: CN0474 . This is a "RR MEDICARE GROUP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 77902674 . This is a "MEDICAID GROUP NUMBER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 410018421 . This is a "RR MEDICARE PIN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 4000501 . This is a "MEDICARE LAB GROUP" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 77009884 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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