Provider Demographics
NPI:1306222757
Name:MIDWEST WELLNESS LLC
Entity Type:Organization
Organization Name:MIDWEST WELLNESS LLC
Other - Org Name:MD MEDICAL WEIGHTLOSS AND WELLNESS CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SRINIVASU
Authorized Official - Middle Name:
Authorized Official - Last Name:KESA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-850-7725
Mailing Address - Street 1:6822 E 82ND ST STE 310
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1677
Mailing Address - Country:US
Mailing Address - Phone:317-548-4666
Mailing Address - Fax:317-350-0059
Practice Address - Street 1:6822 E 82ND ST STE 310
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-1677
Practice Address - Country:US
Practice Address - Phone:317-548-4666
Practice Address - Fax:317-350-0059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-08
Last Update Date:2015-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200389120Medicaid
INH70690Medicare UPIN
IN898190C2Medicare PIN