Basic Information
Provider Information
NPI: 1003011834
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SNIADANKO
FirstName: MARK
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4750 HEMPSTEAD STATION DR
Address2:  
City: KETTERING
State: OH
PostalCode: 454295164
CountryCode: US
TelephoneNumber: 8008750136
FaxNumber: 9376193014
Practice Location
Address1: 2600 NAVARRE AVE
Address2:  
City: OREGON
State: OH
PostalCode: 436163207
CountryCode: US
TelephoneNumber: 4196967500
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/20/2007
LastUpdateDate: 10/16/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207P00000X34-008693OHY Allopathic & Osteopathic PhysiciansEmergency Medicine 

ID Information
IDTypeStateIssuerDescription
00000052268801OHBCBS ST CHARLESOTHER
278274305OH MEDICAID
P0043562301OHRRN MCR ST CHARLESOTHER


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