Provider Demographics
NPI:1174940696
Name:MEDICAL WEIGHT LOSS OF NEW YORK, PLLC
Entity type:Organization
Organization Name:MEDICAL WEIGHT LOSS OF NEW YORK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WENDEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-445-0003
Mailing Address - Street 1:6800 E GENESEE ST
Mailing Address - Street 2:SUITE 1501
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1089
Mailing Address - Country:US
Mailing Address - Phone:315-391-9390
Mailing Address - Fax:315-445-0056
Practice Address - Street 1:6800 E GENESEE ST
Practice Address - Street 2:SUITE 1501
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1089
Practice Address - Country:US
Practice Address - Phone:315-391-9390
Practice Address - Fax:315-445-0056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Multi-Specialty
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Multi-Specialty