Provider Demographics
NPI:1811052020
Name:WATERHOUSE, GEORGE (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:WATERHOUSE
Suffix:
Gender:M
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:441 MCALISTER RD
Practice Address - Street 2:STE 2100
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-4126
Practice Address - Country:US
Practice Address - Phone:980-212-6250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20582208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004294400Medicaid
020034960OtherRAILROAD MEDICARE
WY101117100Medicaid
NCNCD459BOtherMEDICARE PTAN
B04226Medicare UPIN
WYW305966Medicare PIN