Provider Demographics
NPI:1427042902
Name:SNELL, MARY B (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:SNELL
Suffix:
Gender:F
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:PO BOX 689711
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53268-9711
Mailing Address - Country:US
Mailing Address - Phone:414-456-3100
Mailing Address - Fax:414-456-3113
Practice Address - Street 1:7400 W RAWSON AVE
Practice Address - Street 2:SUITE 213
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8278
Practice Address - Country:US
Practice Address - Phone:414-525-1506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27902207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31365600Medicaid
WI0007-02475Medicare ID - Type Unspecified
WI684800004Medicare Oscar/Certification
WIB56733Medicare UPIN
WI31365600Medicaid