Provider Demographics
NPI:1558311183
Name:MCDERMOTT, FREDERIC THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:FREDERIC
Middle Name:THOMAS
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 1:751 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2559
Mailing Address - Country:US
Mailing Address - Phone:814-333-5145
Mailing Address - Fax:814-333-5197
Practice Address - Street 1:751 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2559
Practice Address - Country:US
Practice Address - Phone:814-333-5145
Practice Address - Fax:814-333-5197
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD049636L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA747484OtherBLUE SHIELD
PA0014141000004Medicaid
PA0656922000OtherINDEPENDENCE BLUE CROSS
PA219928OtherUPMC
PA300122242Medicare PIN
PA0656922000OtherINDEPENDENCE BLUE CROSS
PA747484NE1Medicare PIN