Basic Information
Provider Information | |||||||||
NPI: | 1689277410 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEDEXPRESS URGENT CARE ALABAMA, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OPTUM VIRTUAL CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1001 CONSOL ENERGY DR | ||||||||
Address2: |   | ||||||||
City: | CANONSBURG | ||||||||
State: | PA | ||||||||
PostalCode: | 153176506 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042252500 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 423 FORTRESS BLVD | ||||||||
Address2: |   | ||||||||
City: | MORGANTOWN | ||||||||
State: | WV | ||||||||
PostalCode: | 265081351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3042252500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/16/2020 | ||||||||
LastUpdateDate: | 03/16/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GALL | ||||||||
AuthorizedOfficialFirstName: | BRETT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR PAYOR CONTRACTING | ||||||||
AuthorizedOfficialTelephone: | 3042252500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/16/2021 |
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 |
No ID Information.