Basic Information
| Provider Information | |||||||||
| NPI: | 1336748367 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WH IL MEDICAL PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WALMART HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST # MS 0445 | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792041258 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 1715 N. KILPATRICK AVE. | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7736876041 | ||||||||
| FaxNumber: | 7732767564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2020 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | PULLURU | ||||||||
| AuthorizedOfficialFirstName: | SOUJANYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4792772500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 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 | 231H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.