Healthcare Provider Details

I. General information

NPI: 1528296167
Provider Name (Legal Business Name): DR. BRANDON SNYDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2009
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3050 MONTVALE DR
SPRINGFIELD IL
62704-4290
US

IV. Provider business mailing address

3050 MONTVALE DR
SPRINGFIELD IL
62704-4290
US

V. Phone/Fax

Practice location:
  • Phone: 217-726-8096
  • Fax:
Mailing address:
  • Phone: 217-726-8096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2015001559
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036137127
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: