Healthcare Provider Details

I. General information

NPI: 1477896348
Provider Name (Legal Business Name): STACY L SNYDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2013
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N MICHIGAN ST 4TH FL
SOUTH BEND IN
46601-1033
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-6892
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number01082192A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: