Basic Information
Provider Information | |||||||||
NPI: | 1093219438 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEDEXPRESS PRIMARY CARE MASSACHUSETTS, P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEDEXPRESS - WATERS CORP MILFORD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1001 CONSOL ENERGY DR | ||||||||
Address2: |   | ||||||||
City: | CANONSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 153176506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042252500 | ||||||||
FaxNumber: | 7247431133 | ||||||||
Practice Location | |||||||||
Address1: | 34 MAPLE ST | ||||||||
Address2: |   | ||||||||
City: | MILFORD | ||||||||
State: | MA | ||||||||
PostalCode: | 017573604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5084822315 | ||||||||
FaxNumber: | 5084822988 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2018 | ||||||||
LastUpdateDate: | 03/21/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GALL | ||||||||
AuthorizedOfficialFirstName: | BRETT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR PAYOR CONTRACTING | ||||||||
AuthorizedOfficialTelephone: | 3042252500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 208D00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.