Provider Demographics
NPI:1942917380
Name:VALEANT MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:VALEANT MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHANI MOHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VUPADHYAYULA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-813-7476
Mailing Address - Street 1:1121 BALTUSROL LN
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-9031
Mailing Address - Country:US
Mailing Address - Phone:704-813-7476
Mailing Address - Fax:
Practice Address - Street 1:1795 DR FRANK GASTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1190
Practice Address - Country:US
Practice Address - Phone:803-326-3500
Practice Address - Fax:893-336-3632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-04
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty