Basic Information
| Provider Information | |||||||||
| NPI: | 1578095485 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDEXPRESS URGENT CARE MINNESOTA P.C. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDEXPRESS URGENT CARE - LAKEVILLE, 160TH ST W | ||||||||
| 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: | 7247434398 | ||||||||
| Practice Location | |||||||||
| Address1: | 7560 160TH ST W | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAKEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550448348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524317299 | ||||||||
| FaxNumber: | 9524315593 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2017 | ||||||||
| LastUpdateDate: | 06/01/2017 | ||||||||
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| AuthorizedOfficialLastName: | GALL | ||||||||
| AuthorizedOfficialFirstName: | BRETT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR PAYOR CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 3042252500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 1588025332 | 05 | MN | MEDICAID |