Provider Demographics
NPI:1689902199
Name:MACDERMOTT GROUP, LLC
Entity Type:Organization
Organization Name:MACDERMOTT GROUP, LLC
Other - Org Name:ORLANDO RESORTS SPINE & BODY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-697-6994
Mailing Address - Street 1:2940 MALLORY CIR STE 205
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34747-1818
Mailing Address - Country:US
Mailing Address - Phone:407-507-6976
Mailing Address - Fax:
Practice Address - Street 1:2940 MALLORY CIR STE 205
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34747-1818
Practice Address - Country:US
Practice Address - Phone:407-507-6976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MACDERMOTT GROUP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-20
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1689902199OtherGROUP NPI
FL2201BOtherBCBS
FL1689902199OtherGROUP NPI
FL2201BOtherBCBS