MEDICARE: MR. MICHAEL LEE WATERS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician		IL

General Provider Information

NPI Number	:	1477536993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL LEE WATERS MD

Provider Business Mailing Address
First Line	:	505 E GRANT ST
Second Line	:	SUITE 110
City	:	MACOMB
State	:	IL
Zip	:	61455-3352
Country	:	US
Telephone Number	:	309-833-1733
Fax Number	:	309-836-2369

Provider Business Practice Location Address
First Line	:	505 E GRANT ST
Second Line	:	SUITE 110
City	:	MACOMB
State	:	IL
Zip	:	61455-3352
Country	:	US
Telephone Number	:	309-833-1733
Fax Number	:	309-836-2369

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	07/08/2007

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