Basic Information
Provider Information | |||||||||
NPI: | 1831202126 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SNYDER | ||||||||
FirstName: | COURTNEY | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7602 CENTRAL AVE | ||||||||
Address2: | STAPELEY BLDG SUITE 101 | ||||||||
City: | PHILA | ||||||||
State: | PA | ||||||||
PostalCode: | 191112443 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2159692900 | ||||||||
FaxNumber: | 2159691856 | ||||||||
Practice Location | |||||||||
Address1: | 7602 CENTRAL AVE | ||||||||
Address2: | STAPELEY BLDG SUITE 101 | ||||||||
City: | PHILA | ||||||||
State: | PA | ||||||||
PostalCode: | 191112443 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2159692900 | ||||||||
FaxNumber: | 2159691856 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2006 | ||||||||
LastUpdateDate: | 02/11/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS004056L | PA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 19590 | 01 |   | AETNA | OTHER | 0045870000 | 01 |   | BLUE SHIELD | OTHER | 008525480001 | 05 | PA |   | MEDICAID |