Provider Demographics
NPI:1699952606
Name:WATERS FAMILY HEALTH CARE
Entity type:Organization
Organization Name:WATERS FAMILY HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:662-365-3253
Mailing Address - Street 1:305 MILL ST
Mailing Address - Street 2:
Mailing Address - City:BALDWYN
Mailing Address - State:MS
Mailing Address - Zip Code:38824
Mailing Address - Country:US
Mailing Address - Phone:662-365-3253
Mailing Address - Fax:662-365-3484
Practice Address - Street 1:305 MILL ST
Practice Address - Street 2:
Practice Address - City:BALDWYN
Practice Address - State:MS
Practice Address - Zip Code:38824
Practice Address - Country:US
Practice Address - Phone:662-365-3253
Practice Address - Fax:662-365-3484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR574929207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03222231Medicaid
MSC02851Medicare PIN
MSS70987Medicare UPIN