Basic Information
| Provider Information | |||||||||
| NPI: | 1780681122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MURPHY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 263 FARMINGTON AVENUE | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061192212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606797503 | ||||||||
| FaxNumber: | 8606791610 | ||||||||
| Practice Location | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060300001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606794600 | ||||||||
| FaxNumber: | 8606791248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 038784 | CT | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ND0900X | 038784 | CT | Y | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
ID Information
| ID | Type | State | Issuer | Description | 1387845 | 05 | CT | MEDICAID |