Healthcare Provider Details

I. General information

NPI: 1548440415
Provider Name (Legal Business Name): MICHELLE SUZANNE VICTAIN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KNOWLSON AVE
BEAVER FALLS PA
15010-1634
US

IV. Provider business mailing address

100 KNOWLSON AVENUE CHIPPEWA TOWNSHIP
BEAVER FALLS PA
15010-1634
US

V. Phone/Fax

Practice location:
  • Phone: 724-891-2100
  • Fax:
Mailing address:
  • Phone: 724-891-2100
  • Fax: 724-891-2734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberOT010937
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: