Basic Information
| Provider Information | |||||||||
| NPI: | 1821372624 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDEXPRESS URGENT CARE, PC - VIRGINIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEDEXPRESS URGENT CARE - BLUEFIELD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 4003 COLLEGE AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | BLUEFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 246052043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763222085 | ||||||||
| FaxNumber: | 2763222590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2011 | ||||||||
| LastUpdateDate: | 05/20/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BUGIN | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF 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 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 | 1215219878 | 05 | VA | MEDICAID | 3810022525 | 05 | WV | MEDICAID |