Provider Demographics
NPI:1447458419
Name:JON A. SNELLGROVE DPM PA
Entity type:Organization
Organization Name:JON A. SNELLGROVE DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:SNELLGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-470-0477
Mailing Address - Street 1:1320 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-5926
Mailing Address - Country:US
Mailing Address - Phone:850-470-0477
Mailing Address - Fax:850-470-0187
Practice Address - Street 1:6202 N. 9TH AVE.
Practice Address - Street 2:SUITE 4
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8291
Practice Address - Country:US
Practice Address - Phone:850-470-0477
Practice Address - Fax:850-470-0187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3012213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5488520001Medicare NSC
FLK8440Medicare PIN