Healthcare Provider Details

I. General information

NPI: 1497108468
Provider Name (Legal Business Name): MIDWEST WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6822 E 82ND ST SUITE 310
INDIANAPOLIS IN
46250-1676
US

IV. Provider business mailing address

6822 E 82ND ST SUITE 310
INDIANAPOLIS IN
46250-1676
US

V. Phone/Fax

Practice location:
  • Phone: 317-548-4666
  • Fax:
Mailing address:
  • Phone: 317-548-4666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SRINIVASU KESA
Title or Position: PRESIDENT
Credential: MD
Phone: 317-548-4666