Provider Demographics
NPI:1265488175
Name:SNEIDER, MARK SIMON (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:SIMON
Last Name:SNEIDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:612-262-4258
Practice Address - Street 1:255 SMITH AVE N STE 100
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2518
Practice Address - Country:US
Practice Address - Phone:651-241-5000
Practice Address - Fax:651-241-7678
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN51445208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3338573Medicaid
TN4125086OtherBC/BS TN
MN020003010Medicare PIN
TN4125086OtherBC/BS TN