Provider Demographics
NPI:1780890624
Name:BICKERSTAFF, MICHAEL DAVID (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:BICKERSTAFF
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 78
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:PA
Mailing Address - Zip Code:18421-9715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:RR 1 BOX 78
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:PA
Practice Address - Zip Code:18421-9715
Practice Address - Country:US
Practice Address - Phone:570-470-1530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007419L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAV05856Medicare UPIN
PA093073JQ3Medicare ID - Type UnspecifiedCHIROPRACTOR