Basic Information
| Provider Information | |||||||||
| NPI: | 1790077824 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL CENTER FOR HEALTHY WEIGHT LOSS, INC. | ||||||||
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| OtherOrganizationName: | LIVELYTE MEDICAL WEIGHT MANAGEMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2419 FOX CREEK LN | ||||||||
| Address2: | |||||||||
| City: | DAVIDSONVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210351152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107219153 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2000 MEDICAL PKWY | ||||||||
| Address2: | SUITE 605 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102665667 | ||||||||
| FaxNumber: | 4102669332 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2011 | ||||||||
| LastUpdateDate: | 05/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | MICHELSEN | ||||||||
| AuthorizedOfficialFirstName: | EMILY | ||||||||
| AuthorizedOfficialMiddleName: | ULMER | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4107219153 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | D26199 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.