MEDICARE: DERMOT M MCDERMOTT PA-C

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	363AM0700X	Medical Physician Assistant	000997	CT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	970019423	OTHER	CT	RAIL ROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000997	OTHER	CT	CONNECTICARE
2	290000997CT01	OTHER	CT	ANTHEM BC/BS
3	P2531898	OTHER	CT	OXFORD
4	0Q2937	OTHER	CT	HELATH NET
5	061561581	OTHER	CT	UNITED HEALTHCARE
7	369530	OTHER	CT	WELLCARE OF CT

General Provider Information

NPI Number	:	1457352437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERMOT M MCDERMOTT PA-C

Provider Business Mailing Address
First Line	:	874 HOWARD AVE
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06519-1106
Country	:	US
Telephone Number	:	203-688-8200
Fax Number	:	203-688-8204

Provider Business Practice Location Address
First Line	:	874 HOWARD AVE
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06519-1106
Country	:	US
Telephone Number	:	203-688-8200
Fax Number	:	203-688-8204

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

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	01/09/2009

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Directions to “ DERMOT M MCDERMOTT PA-C” Practice Location

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