Basic Information
| Provider Information | |||||||||
| NPI: | 1235138280 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDEXPRESS URGENT CARE PLLC-MORGANTOWN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1751 EARL L CORE ROAD | ||||||||
| Address2: | |||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042252500 | ||||||||
| FaxNumber: | 3049856350 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 DON KNOTTS BLVD | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | MORGANTOWN | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265016734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042913627 | ||||||||
| FaxNumber: | 3042843630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 02/14/2012 | ||||||||
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| AuthorizedOfficialLastName: | BUGIN | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF PAYOR CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 3042252500 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDEXPRESS URGENT CARE PLLC-MORGANTOWN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 00043 | 01 | WV | STATE LICENSE | OTHER | 3810002602 | 05 | WV | MEDICAID | 51D0990987 | 01 | WV | CLIA | OTHER |