Healthcare Provider Details

I. General information

NPI: 1467820159
Provider Name (Legal Business Name): MICHAEL KENT SNIDER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 08/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 MIAMI VALLEY DR STE 350
CENTERVILLE OH
45459-1294
US

IV. Provider business mailing address

3170 KETTERING BLVD BLDG B 3RD FL
MORAINE OH
45439-1924
US

V. Phone/Fax

Practice location:
  • Phone: 937-424-2469
  • Fax: 937-424-2479
Mailing address:
  • Phone: 937-991-3188
  • Fax: 937-223-9811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004468
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: