Provider Demographics
NPI:1497108468
Name:MIDWEST WELLNESS LLC
Entity Type:Organization
Organization Name:MIDWEST WELLNESS LLC
Other - Org Name:MD MEDICAL WEIGHT LOSS AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
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:317-548-4666
Mailing Address - Street 1:6822 E 82ND ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-1676
Mailing Address - Country:US
Mailing Address - Phone:317-548-4666
Mailing Address - Fax:
Practice Address - Street 1:6822 E 82ND ST
Practice Address - Street 2:SUITE 310
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-1676
Practice Address - Country:US
Practice Address - Phone:317-548-4666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN207R00000X
207RB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Multi-Specialty