Healthcare Provider Details

I. General information

NPI: 1396193454
Provider Name (Legal Business Name): HELEN GERSENY WATERMAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 12/30/2020
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 N ASHLAND AVE
CHICAGO IL
60657-4004
US

IV. Provider business mailing address

2900 N ASHLAND AVE
CHICAGO IL
60657-4004
US

V. Phone/Fax

Practice location:
  • Phone: 773-348-8300
  • Fax:
Mailing address:
  • Phone: 773-348-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6160-851
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number68057
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036.152851
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: