MEDICARE: MICHAEL J MURDOCK M.S. CCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	074	WY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01028456	OTHER		ASHA CERTIFICATION
2	074	OTHER	WY	STATE LICENSURE
3	074	OTHER	WY	WYOMING SPEECH AND HEARING ASSOCIATION
4	2226	OTHER	CO	COLORADO SPEECH AND HEARING ASSOCIATION
5	163770	OTHER	CA	CALIFORNIA SPEECH HEARING

General Provider Information

NPI Number	:	1104024033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL J MURDOCK M.S. CCC

Provider Business Mailing Address
First Line	:	1425 BUENA VISTA DR
Second Line	:	PO BOX 202
City	:	LANDER
State	:	WY
Zip	:	82520-3463
Country	:	US
Telephone Number	:	307-349-2998
Fax Number	:

Provider Business Practice Location Address
First Line	:	1425 BUENA VISTA DR
Second Line	:
City	:	LANDER
State	:	WY
Zip	:	82520-3463
Country	:	US
Telephone Number	:	307-349-2998
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2007
Last Update Date	:	02/17/2015

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