Healthcare Provider Details

I. General information

NPI: 1174940696
Provider Name (Legal Business Name): MEDICAL WEIGHT LOSS OF NEW YORK, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2014
Last Update Date: 03/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 E GENESEE ST SUITE 1501
FAYETTEVILLE NY
13066-1089
US

IV. Provider business mailing address

6800 E GENESEE ST SUITE 1501
FAYETTEVILLE NY
13066-1089
US

V. Phone/Fax

Practice location:
  • Phone: 315-391-9390
  • Fax: 315-445-0056
Mailing address:
  • Phone: 315-391-9390
  • Fax: 315-445-0056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: BRYAN T WENDEL
Title or Position: PRACTICE MANAGER
Credential:
Phone: 315-445-0003