1659784056 NPI number — MEDEXPRESS URGENT CARE, INC - WEST VIRGINIA

Table of content: (NPI 1659784056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659784056 NPI number — MEDEXPRESS URGENT CARE, INC - WEST VIRGINIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDEXPRESS URGENT CARE, INC - WEST VIRGINIA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MEDEXPRESS URGENT CARE - MORGANTOWN, MAPLE DRIVE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659784056
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
423 FORTRESS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORGANTOWN
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26508-1351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-225-2500
Provider Business Mailing Address Fax Number:
304-985-6350

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
956 MAPLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MORGANTOWN
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26505-2813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-291-5805
Provider Business Practice Location Address Fax Number:
304-291-5811
Provider Enumeration Date:
06/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KIMBALL
Authorized Official First Name:
JOY
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTRACT MANAGER
Authorized Official Telephone Number:
763-349-6740

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01612 . This is a "STATE LICENSE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1659784056-001 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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