Provider Demographics
NPI:1346462801
Name:RENEE L WATERS, MD PC
Entity Type:Organization
Organization Name:RENEE L WATERS, MD PC
Other - Org Name:IVY RIDGE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TOD
Authorized Official - Last Name:KEYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-205-7799
Mailing Address - Street 1:285 ELM ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-8233
Mailing Address - Country:US
Mailing Address - Phone:770-205-9457
Mailing Address - Fax:678-947-4060
Practice Address - Street 1:285 ELM ST
Practice Address - Street 2:SUITE 102
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-8233
Practice Address - Country:US
Practice Address - Phone:770-205-9457
Practice Address - Fax:678-947-4060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00650339DMedicaid