Provider Demographics
NPI:1629109467
Name:EDWARD MCDERMOTT, MD
Entity Type:Organization
Organization Name:EDWARD MCDERMOTT, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-447-1475
Mailing Address - Street 1:276R MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320
Mailing Address - Country:US
Mailing Address - Phone:860-447-1475
Mailing Address - Fax:860-447-8598
Practice Address - Street 1:276R MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-447-1475
Practice Address - Fax:860-447-8598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT20822207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010020822CT03OtherANTHEM BLUE CROSS
CTDB1041OtherRAILROAD MEDICARE
CT001208222Medicaid
CT030963OtherHEALTH NET
CT010020822CT03OtherANTHEM BLUE CROSS