Healthcare Provider Details

I. General information

NPI: 1164123790
Provider Name (Legal Business Name): SIDNEY M WATERS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 RAVENWOOD AVE
BALTIMORE MD
21213-1648
US

IV. Provider business mailing address

3330 RAVENWOOD AVE
BALTIMORE MD
21213-1648
US

V. Phone/Fax

Practice location:
  • Phone: 443-929-0406
  • Fax:
Mailing address:
  • Phone: 443-929-0406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: