Healthcare Provider Details

I. General information

NPI: 1578523825
Provider Name (Legal Business Name): WAYNE MICHAEL MCDERMOTT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 09/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1543 AMBERLEY FOREST ROAD
VIRGINIA BEACH VA
23453
US

IV. Provider business mailing address

1543 AMBERLEY FOREST ROAD
VIRGINIA BEACH VA
23453
US

V. Phone/Fax

Practice location:
  • Phone: 757-471-7700
  • Fax: 757-471-9541
Mailing address:
  • Phone: 757-471-7700
  • Fax: 757-471-9541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101037511
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number0101037511
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: