Provider Demographics
NPI:1629048053
Name:MCDERMOTT, DANIEL E (PA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:E
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 65274
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28265-0274
Mailing Address - Country:US
Mailing Address - Phone:800-377-8721
Mailing Address - Fax:304-523-2241
Practice Address - Street 1:200 W LORAIN ST
Practice Address - Street 2:
Practice Address - City:OBERLIN
Practice Address - State:OH
Practice Address - Zip Code:44074-1026
Practice Address - Country:US
Practice Address - Phone:440-775-1211
Practice Address - Fax:440-775-9118
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-0655363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000378667OtherBLUECROSS BLUESHIELD
OHMCPA11974Medicare PIN
S62104Medicare UPIN