Basic Information
| Provider Information | |||||||||
| NPI: | 1174264337 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MC MEDICAL LLC | ||||||||
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| OtherOrganizationName: | WALMART HEALTH VIRTUAL CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6910 E CHAUNCEY LN STE 220 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850545162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802473366 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3615 CHARLES HARDY PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301579472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708637200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2022 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | PULLURU | ||||||||
| AuthorizedOfficialFirstName: | SOUJANYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6305454046 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 104100000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.