Provider Demographics
NPI:1437869963
Name:MC MEDICAL LLC
Entity Type:Organization
Organization Name:MC MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOUJANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:PULLURU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-545-4046
Mailing Address - Street 1:702 SW 8TH ST # MS 0445
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72716-0445
Mailing Address - Country:US
Mailing Address - Phone:479-258-2080
Mailing Address - Fax:
Practice Address - Street 1:16313 NEW INDEPENDENCE PKWY
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-8113
Practice Address - Country:US
Practice Address - Phone:321-221-6309
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-23
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty