Basic Information
| Provider Information | |||||||||
| NPI: | 1912102229 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | THADDEUS | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3010 W NEWPORT AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606184356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082165459 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2160 S 1ST AVE | ||||||||
| Address2: | LOYOLA UNIVERSITY MEDICAL CNTR - DEPT OBGYN | ||||||||
| City: | MAYWOOD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601533328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082164033 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 09/09/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 35089915 | OH | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VM0101X | 036131903 | IL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3068782 | 05 | OH | MEDICAID |