Basic Information
| Provider Information | |||||||||
| NPI: | 1245714849 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOTAL ACCESS URGENT CARE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13861 MANCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | BALLWIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630114503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142384660 | ||||||||
| FaxNumber: | 3142703694 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 S BIG BEND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144498677 | ||||||||
| FaxNumber: | 3144498678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2018 | ||||||||
| LastUpdateDate: | 09/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | BRUCKEL | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3149612255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TOTAL ACCESS URGENT CARE, PC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 000015584 | 01 | PTAN | OTHER |