1164452637 NPI number — DR. MARC S MCDERMOTT MD

Table of content: DR. MARC S MCDERMOTT MD (NPI 1164452637)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164452637 NPI number — DR. MARC S MCDERMOTT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCDERMOTT
Provider First Name:
MARC
Provider Middle Name:
S
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1164452637
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
77 HOSPITAL AVENUE, SUITE 302
Provider Second Line Business Mailing Address:
AMBULATORY CARE CENTER
Provider Business Mailing Address City Name:
NORTH ADAMS
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01247-2538
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
413-663-8365
Provider Business Mailing Address Fax Number:
413-662-2363

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
77 HOSPITAL AVENUE, SUITE 302
Provider Second Line Business Practice Location Address:
AMBULATORY CARE CENTER
Provider Business Practice Location Address City Name:
NORTH ADAMS
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01247-2538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
413-663-8365
Provider Business Practice Location Address Fax Number:
413-662-2363
Provider Enumeration Date:
07/03/2006

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: 208000000X , with the licence number:  5223923-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080P0204X , with the licence number: 5223923-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0142817 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100503184 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 121348200 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: D5339 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806860000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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