Basic Information
| Provider Information | |||||||||
| NPI: | 1700159027 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDEXPRESS URGENT CARE, INC - WEST VIRGINIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MEDEXPRESS URGENT CARE - BECKLEY CROSSING | ||||||||
| 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: | 7247431133 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 BECKLEY CROSSING SHPG CTR | ||||||||
| Address2: | |||||||||
| City: | BECKLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 258017110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042526639 | ||||||||
| FaxNumber: | 3042526681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2012 | ||||||||
| LastUpdateDate: | 09/21/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUGIN | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF PAYOR CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 3042252500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
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 | 01612 | 01 | WV | STATE LICENSE | OTHER | 3810022514 | 05 | WV | MEDICAID |