Provider Demographics
NPI:1699142612
Name:SI MEDICAL WEIGHT LOSS
Entity type:Organization
Organization Name:SI MEDICAL WEIGHT LOSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:CANDLER
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:618-741-4454
Mailing Address - Street 1:123 LINCOLN PLACE CT
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-5884
Mailing Address - Country:US
Mailing Address - Phone:618-234-5677
Mailing Address - Fax:618-234-5679
Practice Address - Street 1:123 LINCOLN PLACE CT
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5884
Practice Address - Country:US
Practice Address - Phone:618-234-5677
Practice Address - Fax:618-234-5679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012741261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care