1811014806 NPI number — WATERSTONE CLINIC P.C.

Table of content: (NPI 1811014806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811014806 NPI number — WATERSTONE CLINIC P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WATERSTONE CLINIC P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811014806
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
314 W SUPERIOR ST
Provider Second Line Business Mailing Address:
SUITE 902
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55802-1805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-727-4531
Provider Business Mailing Address Fax Number:
218-727-4211

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
314 W SUPERIOR ST
Provider Second Line Business Practice Location Address:
SUITE 902
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55802-1805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-727-4531
Provider Business Practice Location Address Fax Number:
218-727-4211
Provider Enumeration Date:
03/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BAMBENEK
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
PETER
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
218-727-4531

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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