Provider Demographics
NPI:1538119987
Name:MCDERMOTT, MICHAEL J (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14532 JOHN HUMPHREY DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462
Mailing Address - Country:US
Mailing Address - Phone:708-403-1611
Mailing Address - Fax:708-403-1650
Practice Address - Street 1:14532 JOHN HUMPHREY DR
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-2640
Practice Address - Country:US
Practice Address - Phone:708-403-1611
Practice Address - Fax:708-403-1650
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004034213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
60101286OtherBLUE CROSS
IL363863248OtherMEDICARE
IL363863248OtherEDI
ILIL4307OtherMEDICARE PTAN
IL016004034Medicaid
IL363863248OtherBLUE CROSS BLUE SHIELD OF IL
T38876Medicare UPIN