Provider Demographics
NPI:1205003472
Name:WATERER, REBECCA RIEVES (MD)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:RIEVES
Last Name:WATERER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:DEPT. OF EMPLOYEE/STUDENT HEALTH
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-1185
Mailing Address - Fax:601-984-1189
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPT. OF EMPLOYEE/STUDENT HEALTH
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-1185
Practice Address - Fax:601-984-1189
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11012282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSC48361Medicare UPIN