Basic Information
Provider Information | |||||||||
NPI: | 1174676829 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCDEVITT | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | THOMAS | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1035 SOUTHCREST DR | ||||||||
Address2: | SUITE 250 | ||||||||
City: | STOCKBRIDGE | ||||||||
State: | GA | ||||||||
PostalCode: | 302816118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709969945 | ||||||||
FaxNumber: | 7709967355 | ||||||||
Practice Location | |||||||||
Address1: | 1035 SOUTHCREST DR | ||||||||
Address2: | SUITE 250 | ||||||||
City: | STOCKBRIDGE | ||||||||
State: | GA | ||||||||
PostalCode: | 302816118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7709969945 | ||||||||
FaxNumber: | 7709967355 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/18/2007 | ||||||||
LastUpdateDate: | 03/17/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 037025 | GA | Y |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | 1861090-012 | 01 | GA | CIGNA | OTHER | 581800973 | 01 | GA | UNITED HEALTHCARE | OTHER | 770001325 | 01 | GA | MEDICARE RAILROAD | OTHER | 281529 | 01 | GA | WELLCARE CHOICE PLAN | OTHER | 000546521C | 05 | GA |   | MEDICAID | 0486348 | 01 | GA | AETNA | OTHER | 52451306002 | 01 | GA | BLUE CROSS BLUE SHIELD | OTHER |