MEDICARE: MATTHEW REED HERRILL M.S., ATC, LAT

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	2255A2300X	Athletic Trainer	366	OK

General Provider Information

NPI Number	:	1457387425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW REED HERRILL M.S., ATC, LAT

Provider Business Mailing Address
First Line	:	ATHLETICS CENTER
Second Line	:	ATHLETIC TRAINING ROOM
City	:	STILLWATER
State	:	OK
Zip	:	74078
Country	:	US
Telephone Number	:	405-744-1340
Fax Number	:	405-744-0358

Provider Business Practice Location Address
First Line	:	ATHLETICS CENTER
Second Line	:	ATHLETIC TRAINING ROOM
City	:	STILLWATER
State	:	OK
Zip	:	74078-0001
Country	:	US
Telephone Number	:	405-744-1340
Fax Number	:	405-744-0358

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

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	07/08/2007

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