Provider Demographics
NPI:1033441936
Name:MINI-MEDIC
Entity Type:Organization
Organization Name:MINI-MEDIC
Other - Org Name:GLENN R. MCDERMOTT, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-343-4221
Mailing Address - Street 1:1788 REPUBLIC RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-4552
Mailing Address - Country:US
Mailing Address - Phone:757-343-4221
Mailing Address - Fax:
Practice Address - Street 1:1788 REPUBLIC RD
Practice Address - Street 2:SUITE 400
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-4552
Practice Address - Country:US
Practice Address - Phone:757-343-4221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034588207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA016800C10Medicare PIN