Healthcare Provider Details

I. General information

NPI: 1093158818
Provider Name (Legal Business Name): MACI MCDERMOTT M.D,
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 09/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3606 MACLAY BLVD STE 102
TALLAHASSEE FL
32312
US

IV. Provider business mailing address

3606 MACLAY BLVD. STE 102
TALLAHASSEE FL
32312
US

V. Phone/Fax

Practice location:
  • Phone: 850-877-1162
  • Fax: 850-671-5009
Mailing address:
  • Phone: 850-877-1162
  • Fax: 850-671-5009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME129263
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: