Provider Demographics
NPI:1427309293
Name:MMC DOC MD LLC
Entity type:Organization
Organization Name:MMC DOC MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SRINIVASA
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-341-6539
Mailing Address - Street 1:7298 W AVENIDA DEL SOL
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-3257
Mailing Address - Country:US
Mailing Address - Phone:623-341-6539
Mailing Address - Fax:708-801-7128
Practice Address - Street 1:13216 N PLAZA DEL RIO BLVD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4907
Practice Address - Country:US
Practice Address - Phone:623-977-5003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34403208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ956740OtherAHCCCS ID - AZ MEDICAID
AZ139804Medicare PIN