Provider Demographics
NPI:1790077824
Name:MEDICAL CENTER FOR HEALTHY WEIGHT LOSS, INC.
Entity Type:Organization
Organization Name:MEDICAL CENTER FOR HEALTHY WEIGHT LOSS, INC.
Other - Org Name:LIVELYTE MEDICAL WEIGHT MANAGEMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:ULMER
Authorized Official - Last Name:MICHELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-721-9153
Mailing Address - Street 1:2419 FOX CREEK LN
Mailing Address - Street 2:
Mailing Address - City:DAVIDSONVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21035-1152
Mailing Address - Country:US
Mailing Address - Phone:410-721-9153
Mailing Address - Fax:
Practice Address - Street 1:2000 MEDICAL PKWY
Practice Address - Street 2:SUITE 605
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3742
Practice Address - Country:US
Practice Address - Phone:410-266-5667
Practice Address - Fax:410-266-9332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-08
Last Update Date:2011-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD26199261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty