Provider Demographics
NPI:1316439557
Name:CENTRAL OHIO WEIGHT LOSS CLINIC,LLC
Entity type:Organization
Organization Name:CENTRAL OHIO WEIGHT LOSS CLINIC,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BISUTTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-218-6313
Mailing Address - Street 1:196 BRIGHTON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1022
Mailing Address - Country:US
Mailing Address - Phone:614-218-6313
Mailing Address - Fax:
Practice Address - Street 1:4041 N HIGH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214
Practice Address - Country:US
Practice Address - Phone:614-927-9212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-04
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.090054207QB0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Single Specialty