Provider Demographics
NPI:1750421194
Name:WATERLOO MEDICAL CENTER PC
Entity type:Organization
Organization Name:WATERLOO MEDICAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:NOBBE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-939-7400
Mailing Address - Street 1:966 S LIBRARY ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-1484
Mailing Address - Country:US
Mailing Address - Phone:618-939-7400
Mailing Address - Fax:618-939-7434
Practice Address - Street 1:966 S LIBRARY ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1484
Practice Address - Country:US
Practice Address - Phone:618-939-7400
Practice Address - Fax:618-939-7434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-036716183500000X
IL038-007391111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL352110Medicare PIN