Healthcare Provider Details

I. General information

NPI: 1720194483
Provider Name (Legal Business Name): IVAN T. SNOWDEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 HEALTH CENTER DRIVE
MATTOON IL
61938
US

IV. Provider business mailing address

834 N SEMINARY ST SUITE 100
GALESBURG IL
61401-2852
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-4006
  • Fax: 217-258-4120
Mailing address:
  • Phone: 309-343-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-058846
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: