=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073715090
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL DALLEY SNELL M.D, M.P.H.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2007
-----------------------------------------------------
Last Update Date | 11/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 HOSPITAL WAY
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83201-5175
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-232-7760
-----------------------------------------------------
Fax | 208-232-1950
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4107
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83205-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-232-7760
-----------------------------------------------------
Fax | 208-232-1950
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP3000X
-----------------------------------------------------
Taxonomy Name | Pediatric Anesthesiology Physician
-----------------------------------------------------
License Number | 76558
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | M-10006
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------