Provider Demographics
NPI:1790715092
Name:SNYDER, LISA E (MD)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:E
Last Name:SNYDER
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 1:6501 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2932
Mailing Address - Country:US
Mailing Address - Phone:309-692-8110
Mailing Address - Fax:309-692-8673
Practice Address - Street 1:6501 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2932
Practice Address - Country:US
Practice Address - Phone:309-692-8110
Practice Address - Fax:309-692-8673
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-073903208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL009033OtherHEALTH ALLIANCE PROVIDER
IL036073903Medicaid
IL250004431OtherRAIL ROAD MEDICARE ID
IL370681567-02OtherJOHN DEERE PROVIDER NUMBE
ILF39072Medicare UPIN
ILL21899Medicare PIN