Provider Demographics
NPI:1952359473
Name:STANLEY J. WATERS MD
Entity Type:Organization
Organization Name:STANLEY J. WATERS MD
Other - Org Name:AMERICANA ORTHOPAEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:208-322-0485
Mailing Address - Street 1:1673 SHORELINE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6736
Mailing Address - Country:US
Mailing Address - Phone:208-322-0485
Mailing Address - Fax:208-378-8228
Practice Address - Street 1:1673 SHORELINE DR
Practice Address - Street 2:STE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6736
Practice Address - Country:US
Practice Address - Phone:208-322-0485
Practice Address - Fax:208-378-8228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6247207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8J893OtherBLUE CROSS GROUP #
IDF58733Medicare UPIN
ID1376935Medicare ID - Type UnspecifiedMEDICARE GROUP #
ID8J893OtherBLUE CROSS GROUP #
ID1376935Medicare PIN