Provider Demographics
NPI:1326192386
Name:WATERHOUSE, MAURINE (MD)
Entity Type:Individual
Prefix:DR
First Name:MAURINE
Middle Name:
Last Name:WATERHOUSE
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 1:4001 KRESGE WAY
Mailing Address - Street 2:SUITE 320
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4640
Mailing Address - Country:US
Mailing Address - Phone:502-895-5850
Mailing Address - Fax:
Practice Address - Street 1:4001 KRESGE WAY
Practice Address - Street 2:SUITE 320
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4640
Practice Address - Country:US
Practice Address - Phone:502-895-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY29987208200000X, 2082S0099X, 2082S0105X, 2086S0122X, 2086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000048443OtherBLUE CROSS
KY1051840OtherPASSPORT
KY4330141OtherAETNA
KY64299878Medicaid
KYF68080Medicare UPIN
KY1397711Medicare ID - Type UnspecifiedMEDICARE