Basic Information
| Provider Information | |||||||||
| NPI: | 1548331226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNIDER | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 510 GRAVES AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | ERLANGER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410183309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593415014 | ||||||||
| FaxNumber: | 8593415136 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 GRAVES AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | ERLANGER | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410183309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593415014 | ||||||||
| FaxNumber: | 8593415136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 09/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 16835 | KY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 174400000X | 16835 | KY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 64168354 | 05 | KY | MEDICAID |