MEDICARE: MEDICAL WEIGHT LOSS OF NEW YORK, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RB0002X	Obesity Medicine (Internal Medicine) Physician
2	207QB0002X	Obesity Medicine (Family Medicine) Physician

General Provider Information

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

Provider Business Mailing Address
First Line	:	6800 E GENESEE ST
Second Line	:	SUITE 1501
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1089
Country	:	US
Telephone Number	:	315-391-9390
Fax Number	:	315-445-0056

Provider Business Practice Location Address
First Line	:	6800 E GENESEE ST
Second Line	:	SUITE 1501
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1089
Country	:	US
Telephone Number	:	315-391-9390
Fax Number	:	315-445-0056

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	BRYAN T WENDEL
Credential	:
Telephone Number	:	315-445-0003

Provider Enumeration Date	:	03/21/2014
Last Update Date	:	03/21/2014

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