Provider Demographics
NPI:1548875529
Name:MURDOCK, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MURDOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53768 JOE WOOD DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-2886
Mailing Address - Country:US
Mailing Address - Phone:586-850-2199
Mailing Address - Fax:
Practice Address - Street 1:7070 MILLER RD
Practice Address - Street 2:
Practice Address - City:SWARTZ CREEK
Practice Address - State:MI
Practice Address - Zip Code:48473-1591
Practice Address - Country:US
Practice Address - Phone:810-564-7995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant