Provider Demographics
NPI:1518205038
Name:WATERSIDE MEDICAL LLC
Entity Type:Organization
Organization Name:WATERSIDE MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-293-4140
Mailing Address - Street 1:5064 SEASHELL AVE
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-2428
Mailing Address - Country:US
Mailing Address - Phone:239-293-4140
Mailing Address - Fax:239-254-3105
Practice Address - Street 1:311 9TH ST N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5885
Practice Address - Country:US
Practice Address - Phone:239-293-4140
Practice Address - Fax:239-254-3105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-17
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLM80046207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHG441AOtherMEDICARE 855-B
FL6783510001Medicare NSC