Basic Information
| Provider Information | |||||||||
| NPI: | 1124415799 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLIANCE XPRESS CARE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALLIANCE XPRESS CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 9TH ST STE E | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261052176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049161293 | ||||||||
| FaxNumber: | 3049161705 | ||||||||
| Practice Location | |||||||||
| Address1: | 919 S CRAIG AVE STE A | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 244261954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409602231 | ||||||||
| FaxNumber: | 5409602245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2015 | ||||||||
| LastUpdateDate: | 08/05/2021 | ||||||||
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| AuthorizedOfficialLastName: | DRUMMOND | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | VP REVENUE CYCLE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 3045365030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 1124415799 | 05 | VA | MEDICAID |