Basic Information
Provider Information | |||||||||
NPI: | 1962684886 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TOTAL ACCESS URGENT CARE P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 13861 MANCHESTER RD | ||||||||
Address2: |   | ||||||||
City: | BALLWIN | ||||||||
State: | MO | ||||||||
PostalCode: | 630114503 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6365560114 | ||||||||
FaxNumber: | 1432703694 | ||||||||
Practice Location | |||||||||
Address1: | 9556 MANCHESTER RD | ||||||||
Address2: |   | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631191313 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3149612255 | ||||||||
FaxNumber: | 3143735757 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2007 | ||||||||
LastUpdateDate: | 05/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRUCKEL | ||||||||
AuthorizedOfficialFirstName: | MATTHEW | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3144580044 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: | 05/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 2005029371 | MO | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
ID | Type | State | Issuer | Description | 000015584 | 01 |   | DME PTAN | OTHER |