Healthcare Provider Details

I. General information

NPI: 1962594754
Provider Name (Legal Business Name): BRUCE CARL KNICKELBEIN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 N 7TH ST SUITE 203
INDIANA PA
15701-1880
US

IV. Provider business mailing address

1265 WAYNE AVE SUITE 201
INDIANA PA
15701-3501
US

V. Phone/Fax

Practice location:
  • Phone: 724-357-7196
  • Fax: 724-357-7279
Mailing address:
  • Phone: 724-349-3290
  • Fax: 724-349-3786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC002328L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: