Healthcare Provider Details

I. General information

NPI: 1467416875
Provider Name (Legal Business Name): DAVID MICHAEL LIFE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 WILLOW TREE WAY
HURRICANE WV
25526-1085
US

IV. Provider business mailing address

PO BOX 4190
BARBOURSVILLE WV
25504-4190
US

V. Phone/Fax

Practice location:
  • Phone: 304-397-3002
  • Fax: 304-397-3007
Mailing address:
  • Phone: 304-399-4405
  • Fax: 304-399-2526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number17526
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number17526
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: