Provider Demographics
NPI:1972613487
Name:MCDERMOTT, TIMOTHY J (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 JEFFERSON AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1532 LONE OAK RD STE 415
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003
Practice Address - Country:US
Practice Address - Phone:270-442-0103
Practice Address - Fax:270-442-0109
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE7468207RC0000X
MOR3N07207RC0000X
NDLT15153207RI0011X
KY51912207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR192825001Medicaid
MO1972613487Medicaid
MO202840617Medicaid
MOP01161167OtherRAILROAD MEDICARE
MO001014054Medicare ID - Type Unspecified
AR5AP87Medicare PIN
AR192825001Medicaid
MO202840617Medicaid
MOP01161167OtherRAILROAD MEDICARE