Provider Demographics
NPI:1366635112
Name:SNYDER, RUSSELL OWEN (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:OWEN
Last Name:SNYDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5170 US RT 60 EAST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2065
Mailing Address - Country:US
Mailing Address - Phone:304-528-4600
Mailing Address - Fax:
Practice Address - Street 1:5170 US RT 60 EAST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705-2065
Practice Address - Country:US
Practice Address - Phone:304-528-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24446207Q00000X
FLTRN11115390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3140587Medicaid
WV3810020506Medicaid
P00928935OtherMEDICARE RAILROAD
WV3810020506Medicaid