Provider Demographics
NPI:1295870384
Name:PHYSICIAN'S WEIGHT MANAGEMENT CENTER
Entity type:Organization
Organization Name:PHYSICIAN'S WEIGHT MANAGEMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ELEANOR
Authorized Official - Last Name:BEAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-935-8878
Mailing Address - Street 1:3537 W FRONT ST
Mailing Address - Street 2:SUITE H
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7941
Mailing Address - Country:US
Mailing Address - Phone:231-935-8878
Mailing Address - Fax:231-935-8901
Practice Address - Street 1:3537 W FRONT ST
Practice Address - Street 2:SUITE H
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7941
Practice Address - Country:US
Practice Address - Phone:231-935-8878
Practice Address - Fax:231-935-8901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1102810071OtherBCBSM
MI1102810071OtherBCBSM