Basic Information
| Provider Information | |||||||||
| NPI: | 1497188841 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDEXPRESS URGENT CARE - NORTHERN NEW JERSEY, PC | ||||||||
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| OtherOrganizationName: | MEDEXPRESS URGENT CARE - TOTOWA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 225 US HIGHWAY 46 | ||||||||
| Address2: | SUITE A | ||||||||
| City: | TOTOWA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 075121817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732560452 | ||||||||
| FaxNumber: | 9732560453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2013 | ||||||||
| LastUpdateDate: | 01/31/2019 | ||||||||
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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 | 207P00000X | N | 193400000X MULTIPLE 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 | 0347116 | 05 | NJ | MEDICAID |