Provider Demographics
NPI:1528203445
Name:MCMAHAN, DEREK (PT)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MCMAHAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8259 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8878
Mailing Address - Country:US
Mailing Address - Phone:219-365-6560
Mailing Address - Fax:219-365-6561
Practice Address - Street 1:601 GATEWAY BLVD N
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-9658
Practice Address - Country:US
Practice Address - Phone:219-921-1444
Practice Address - Fax:219-926-6926
Is Sole Proprietor?:No
Enumeration Date:2008-12-05
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007962A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400018854Medicare PIN
INM400018855Medicare PIN