Provider Demographics
NPI:1578568549
Name:MCDERMOTT, SIOBAN PAULINE (MD)
Entity Type:Individual
Prefix:
First Name:SIOBAN
Middle Name:PAULINE
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 N HIGHWAY A1A APT 610
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-2765
Mailing Address - Country:US
Mailing Address - Phone:321-368-0292
Mailing Address - Fax:
Practice Address - Street 1:101 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-8301
Practice Address - Country:US
Practice Address - Phone:321-984-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83950208100000X
NY201799208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274318300Medicaid
NY01692704Medicaid
NYJ400067010Medicare PIN
FL30215YMedicare PIN