Basic Information
| Provider Information | |||||||||
| NPI: | 1740448430 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDEXPRESS URGENT CARE, PLLC - CHARLESTON | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 719 | ||||||||
| Address2: | |||||||||
| City: | DELLSLOW | ||||||||
| State: | WV | ||||||||
| PostalCode: | 265310719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049853627 | ||||||||
| FaxNumber: | 3049853630 | ||||||||
| Practice Location | |||||||||
| Address1: | 5430 MACCORKLE AVE SE | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253042224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049253627 | ||||||||
| FaxNumber: | 3049251163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2008 | ||||||||
| LastUpdateDate: | 02/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | BUGIN | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF 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 SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 261QU0200X | 01026 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 51D1089045 | 01 | WV | CLIA | OTHER | 3810012430 | 05 | WV | MEDICAID |