Provider Demographics
NPI:1164452637
Name:MCDERMOTT, MARC S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:S
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:77 HOSPITAL AVENUE, SUITE 302
Mailing Address - Street 2:AMBULATORY CARE CENTER
Mailing Address - City:NORTH ADAMS
Mailing Address - State:MA
Mailing Address - Zip Code:01247-2538
Mailing Address - Country:US
Mailing Address - Phone:413-663-8365
Mailing Address - Fax:413-662-2363
Practice Address - Street 1:77 HOSPITAL AVENUE, SUITE 302
Practice Address - Street 2:AMBULATORY CARE CENTER
Practice Address - City:NORTH ADAMS
Practice Address - State:MA
Practice Address - Zip Code:01247-2538
Practice Address - Country:US
Practice Address - Phone:413-663-8365
Practice Address - Fax:413-662-2363
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT5223923-1205208000000X, 2080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0142817Medicaid
NV100503184Medicaid
WY121348200Medicaid
UTD5339Medicaid
ID806860000Medicaid
MT0142817Medicaid
UTH99716Medicare UPIN