Basic Information
| Provider Information | |||||||||
| NPI: | 1487653275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MC DERMOTT | ||||||||
| FirstName: | R. | ||||||||
| MiddleName: | GUY | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 W MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492012218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177876440 | ||||||||
| FaxNumber: | 5177682983 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 W HIGHWAY 22 | ||||||||
| Address2: | |||||||||
| City: | BARRINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600107509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473819600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2005 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036098076 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 04922488 | 01 | IL | BLUE SHIELD OF ILLINOIS | OTHER | 036098076 | 05 | IL | MEDICAID |