Basic Information
| Provider Information | |||||||||
| NPI: | 1518195189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDERMOTT | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | STEVEN | ||||||||
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| Credential: | A.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7757 AUBURN RD STE 15 | ||||||||
| Address2: | |||||||||
| City: | PAINESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440779604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4033500832 | ||||||||
| FaxNumber: | 4405790191 | ||||||||
| Practice Location | |||||||||
| Address1: | 25501 CHAGRIN BLVD | ||||||||
| Address2: | |||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441225603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4403500832 | ||||||||
| FaxNumber: | 4405790191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2009 | ||||||||
| LastUpdateDate: | 08/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 67.000149 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2963637 | 05 | OH | MEDICAID | P00880293 | 01 | OH | RAILROAD MEDICARE | OTHER |