=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427421734
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHELLE L SNYDER, DO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2015
-----------------------------------------------------
Last Update Date | 11/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 328 N 2ND ST SUITE 102
-----------------------------------------------------
City | VINCENNES
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47591-1351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-910-0544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 948
-----------------------------------------------------
City | VINCENNES
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47591-0948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-910-0544
-----------------------------------------------------
Fax | 844-861-8251
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHELLE SNYDER
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 812-910-0544
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 02001984A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------