1154387074 NPI number — AVEREL B SNYDER M.D.

Table of content: AVEREL B SNYDER M.D. (NPI 1154387074)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154387074 NPI number — AVEREL B SNYDER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SNYDER
Provider First Name:
AVEREL
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1154387074
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 70547
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30007-0547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-579-1894
Provider Business Mailing Address Fax Number:
770-579-1899

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5665 PEACHTREE DUNWOODY ROAD
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342-1701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-252-6104
Provider Business Practice Location Address Fax Number:
404-257-1808
Provider Enumeration Date:
04/21/2006

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: 208G00000X , with the licence number:  035769 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000508373G , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000508373H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000508373F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00508373D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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