Healthcare Provider Details

I. General information

NPI: 1780635706
Provider Name (Legal Business Name): MARY SNYDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 5TH ST SUITE 101
RAPID CITY SD
57701-6014
US

IV. Provider business mailing address

3615 5TH ST STE 101
RAPID CITY SD
57701-7360
US

V. Phone/Fax

Practice location:
  • Phone: 605-343-7208
  • Fax: 605-343-7132
Mailing address:
  • Phone: 605-343-7208
  • Fax: 605-343-7132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number21329
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number21329
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number5984
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: