Provider Demographics
NPI:1457300808
Name:MCDERMOTT, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 SAM PERRY BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-4453
Mailing Address - Country:US
Mailing Address - Phone:540-741-1571
Mailing Address - Fax:540-741-1586
Practice Address - Street 1:1001 SAM PERRY BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-4453
Practice Address - Country:US
Practice Address - Phone:540-741-1571
Practice Address - Fax:540-741-1586
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010555622085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA300002492Medicare PIN
300068793Medicare PIN
VA300001894Medicare PIN
300129304Medicare PIN
VA00X146V04Medicare PIN
G28896Medicare UPIN
VA300002493Medicare PIN