Healthcare Provider Details

I. General information

NPI: 1144615113
Provider Name (Legal Business Name): JUSTIN THOMAS SNOW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 S JACKSON ST
LOUISVILLE KY
40202-1675
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-3600
  • Fax:
Mailing address:
  • Phone: 502-588-0325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberME144633
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberTP009
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: