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NPI Code Detail

MEDICARE: MC MEDICAL LLC

MEDICARE: MC MEDICAL LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103T00000XPsychologist
2104100000XSocial Worker
3231H00000XAudiologist
4363L00000XNurse Practitioner
5208D00000XGeneral Practice Physician

General Provider Information

NPI Number : 1356907695
Entity Type Code : Organization
Provider Name (Legal Business Name) : MC MEDICAL LLC
Provider Business Mailing Address
First Line : 702 SW 8TH ST
Second Line :
City : BENTONVILLE
State : AR
Zip : 72716-0445
Country : US
Telephone Number : 770-863-7200
Fax Number :
Provider Business Practice Location Address
First Line : 3615 CHARLES HARDY PKWY STE 200
Second Line :
City : DALLAS
State : GA
Zip : 30157-9472
Country : US
Telephone Number : 770-863-7200
Fax Number : 770-505-5690
Authorized Official
Title or Position : PRESIDENT
Name : SOUJANYA PULLURU
Credential :
Telephone Number : 770-863-7200
Provider Enumeration Date : 05/13/2019
Last Update Date : 12/14/2021

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Directions to “MC MEDICAL LLC ” Practice Location

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