Basic Information
| Provider Information | |||||||||
| NPI: | 1477119725 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDEXPRESS PRIMARY CARE WEST VIRGINIA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 CONSOL ENERGY DR | ||||||||
| Address2: | |||||||||
| City: | CANONSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153176506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042252500 | ||||||||
| FaxNumber: | 7247431133 | ||||||||
| Practice Location | |||||||||
| Address1: | 1709 HARPER RD | ||||||||
| Address2: | |||||||||
| City: | BECKLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 258013311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042568671 | ||||||||
| FaxNumber: | 3042568670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2019 | ||||||||
| LastUpdateDate: | 05/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | GALL | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR PAYOR CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 3042252500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.