Basic Information
| Provider Information | |||||||||
| NPI: | 1215034491 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNOW | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458281613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196785243 | ||||||||
| FaxNumber: | 4196785643 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 HAMILTON ST | ||||||||
| Address2: | |||||||||
| City: | CELINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458221909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199532643 | ||||||||
| FaxNumber: | 4195861257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 34-00-6954 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | BS6021404 | 01 | OH | DEA | OTHER | 2090302 | 05 | OH | MEDICAID |