MEDICARE: MR. MATTHEW JOHN MCDERMOTT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225C00000X	Rehabilitation Counselor

General Provider Information

NPI Number	:	1902015795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW JOHN MCDERMOTT

Provider Business Mailing Address
First Line	:	1405 SAINT ANDREWS DR
Second Line	:
City	:	ELK POINT
State	:	SD
Zip	:	57025-2240
Country	:	US
Telephone Number	:	605-761-0182
Fax Number	:

Provider Business Practice Location Address
First Line	:	1405 SAINT ANDREWS DR
Second Line	:
City	:	ELK POINT
State	:	SD
Zip	:	57025-2240
Country	:	US
Telephone Number	:	605-761-0182
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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