Basic Information
| Provider Information | |||||||||
| NPI: | 1811045198 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SNIDER-THAMMAVONG | ||||||||
| FirstName: | ERICA | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 SYCAMORE CREEK DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450662300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377484211 | ||||||||
| FaxNumber: | 9377483566 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 SYCAMORE CREEK DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGBORO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450662300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377484211 | ||||||||
| FaxNumber: | 9377483566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2007 | ||||||||
| LastUpdateDate: | 11/13/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 237301 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35.094616 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02705888 | 05 | NY | MEDICAID | 0058539 | 05 | OH | MEDICAID |