=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164702189
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARK T. SNYDER M.D. PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2011
-----------------------------------------------------
Last Update Date | 08/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8967 LEWIS AVE
-----------------------------------------------------
City | TEMPERANCE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48182-1656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-224-7900
-----------------------------------------------------
Fax | 734-224-7912
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8967 LEWIS AVE
-----------------------------------------------------
City | TEMPERANCE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48182-1656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-224-7900
-----------------------------------------------------
Fax | 734-224-7912
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/POSITION
-----------------------------------------------------
Name | DR. MARK T SNYDER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 734-224-7900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 4301069243
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------