Basic Information
| Provider Information | |||||||||
| NPI: | 1013998152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDERMOTT | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23340 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631563340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182777500 | ||||||||
| FaxNumber: | 6182774236 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 PARK PL | ||||||||
| Address2: | |||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622262965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182777500 | ||||||||
| FaxNumber: | 6182774236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2005 | ||||||||
| LastUpdateDate: | 10/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 036-061906 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036061906 | 05 | IL | MEDICAID | 0407153 | 01 | IL | UHC | OTHER | 000000010025 | 01 | IL | ESSENCE | OTHER | 122607 | 01 | IL | HEALTHLINK | OTHER | 2788 | 01 | IL | BCBS TRI ST | OTHER | 4545931822 | 05 | IL | MEDICAID | 08221955 | 01 | IL | BCBS | OTHER | 127467 | 01 | IL | GHP | OTHER | 4227190 | 01 | IL | AETNA | OTHER | C45318 | 01 | IL | MERCY | OTHER |