Healthcare Provider Details

I. General information

NPI: 1174930150
Provider Name (Legal Business Name): MC MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2510 REDMOND CIR NW
ROME GA
30165-1913
US

IV. Provider business mailing address

702 SW 8TH ST
BENTONVILLE AR
72716-0445
US

V. Phone/Fax

Practice location:
  • Phone: 706-728-3246
  • Fax: 706-232-6598
Mailing address:
  • Phone: 479-204-8550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SOUJANYA PULLURU
Title or Position: PRESIDENT
Credential:
Phone: 706-728-3246