Provider Demographics
NPI:1811014806
Name:WATERSTONE CLINIC P.C.
Entity Type:Organization
Organization Name:WATERSTONE CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:BAMBENEK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-727-4531
Mailing Address - Street 1:314 W SUPERIOR ST
Mailing Address - Street 2:SUITE 902
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55802-1805
Mailing Address - Country:US
Mailing Address - Phone:218-727-4531
Mailing Address - Fax:218-727-4211
Practice Address - Street 1:314 W SUPERIOR ST
Practice Address - Street 2:SUITE 902
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-1805
Practice Address - Country:US
Practice Address - Phone:218-727-4531
Practice Address - Fax:218-727-4211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty