Healthcare Provider Details

I. General information

NPI: 1700098845
Provider Name (Legal Business Name): CRYSTAL SNIDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 01/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1258 W SOUTH ST SUITE 2
KEWANEE IL
61443-8300
US

IV. Provider business mailing address

1258 W SOUTH ST SUITE 2
KEWANEE IL
61443-8300
US

V. Phone/Fax

Practice location:
  • Phone: 309-853-3677
  • Fax: 309-853-3692
Mailing address:
  • Phone: 309-853-3677
  • Fax: 309-853-3692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036121847
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: