Provider Demographics
NPI:1598068850
Name:MCDERMOTT PODIATRY OF JOLIET PC
Entity Type:Organization
Organization Name:MCDERMOTT PODIATRY OF JOLIET PC
Other - Org Name:MCDERMOTT PODIATRY OF JOLIET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-403-1611
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:60462-2640
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004034213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL4307OtherMEDICARE PTAN
IL016004034Medicaid
ILT38876Medicare UPIN