Provider Demographics
NPI:1871016048
Name:RUSSELL T SNOW, D.O., P.A.
Entity Type:Organization
Organization Name:RUSSELL T SNOW, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:T
Authorized Official - Last Name:SNOW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-454-2050
Mailing Address - Street 1:119 W LOGAN ST STE A
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4732
Mailing Address - Country:US
Mailing Address - Phone:208-454-2050
Mailing Address - Fax:208-454-3554
Practice Address - Street 1:119 W LOGAN ST STE A
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4732
Practice Address - Country:US
Practice Address - Phone:208-454-2050
Practice Address - Fax:208-454-3554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-110207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty