Basic Information
| Provider Information | |||||||||
| NPI: | 1689931446 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDEXPRESS URGENT CARE, PC - TENNESSEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 370 SOUTHPOINTE BLVD | ||||||||
| Address2: | |||||||||
| City: | CANONSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153178572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042252500 | ||||||||
| FaxNumber: | 7247431133 | ||||||||
| Practice Location | |||||||||
| Address1: | 2686 W STATE ST | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376201817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238440026 | ||||||||
| FaxNumber: | 4238440028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2012 | ||||||||
| LastUpdateDate: | 06/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | BUGIN | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF PAYOR CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 3042252500 | ||||||||
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| 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 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 | 1689931446 | 05 | VA | MEDICAID | 1527953 | 05 | TN | MEDICAID |