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General NPI Number Information
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NPI Number | 1245742634
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Entity Type | Individual
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Provider Name | MR. CARL W. MCDERMOTT III
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Gender | Male
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Dates
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Enumeration Date | 10/25/2017
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Last Update Date | 10/25/2017
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Provider Practice Location Address
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Address Line | 142 JENKINS MEMORIAL RD
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City | WELLSTON
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State | OH
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Zip | 45692-9561
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Country | US
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Telephone | 740-384-2119
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Fax |
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Provider Business Mailing Address
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Address Line | 2085 SHARON HOGUE RD
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City | MASURY
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State | OH
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Zip | 44438-8712
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 10715
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License Number State | OH
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