1083680599 NPI number — DR. MARK T MCDERMOTT OD

Table of content: DR. MARK T MCDERMOTT OD (NPI 1083680599)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083680599 NPI number — DR. MARK T MCDERMOTT OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDERMOTT
Provider First Name:
MARK
Provider Middle Name:
T
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083680599
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2353 RICE ST
Provider Second Line Business Mailing Address:
STE. 206
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55113-3739
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-483-8148
Provider Business Mailing Address Fax Number:
651-483-3206

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2353 RICE ST
Provider Second Line Business Practice Location Address:
STE 206
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-483-8148
Provider Business Practice Location Address Fax Number:
651-483-3206
Provider Enumeration Date:
02/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2594 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 02169 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22 07646 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 26613 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 152713400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 615152747 . This is a "METROPOLITAN HEALTH PLAN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 124899 . This is a "U CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 57D32MC . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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