Healthcare Provider Details

I. General information

NPI: 1821362088
Provider Name (Legal Business Name): MATTHEW WARREN HURLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2012
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 BLUES LAKE PKWY
ROLLA MO
65401-8022
US

IV. Provider business mailing address

600 BLUES LAKE PKWY
ROLLA MO
65401-8022
US

V. Phone/Fax

Practice location:
  • Phone: 573-364-8822
  • Fax: 573-341-5969
Mailing address:
  • Phone: 573-364-8822
  • Fax: 573-341-5969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.128703
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2012012827
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: