Healthcare Provider Details

I. General information

NPI: 1942917380
Provider Name (Legal Business Name): VALEANT MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2022
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1795 DR FRANK GASTON BLVD
ROCK HILL SC
29732-1190
US

IV. Provider business mailing address

1121 BALTUSROL LN
WAXHAW NC
28173-9031
US

V. Phone/Fax

Practice location:
  • Phone: 803-326-3500
  • Fax: 893-336-3632
Mailing address:
  • Phone: 704-813-7476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PHANI MOHAN VUPADHYAYULA
Title or Position: MEMBER
Credential: MD
Phone: 704-813-7476