1770042954 NPI number — TOTAL ACCESS URGENT CARE, PC

Table of content: (NPI 1770042954)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770042954 NPI number — TOTAL ACCESS URGENT CARE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOTAL ACCESS URGENT CARE, PC
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:
Provider Other Organization Name Type Code:
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:
1770042954
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13861 MANCHESTER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALLWIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63011-4503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-238-4660
Provider Business Mailing Address Fax Number:
314-270-3694

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6940 S LINDBERGH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63125-4219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-380-8527
Provider Business Practice Location Address Fax Number:
314-380-8528
Provider Enumeration Date:
03/18/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BRUCKEL
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
314-961-2255

Provider Taxonomy Codes

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

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

  • Identifier: 000015584 . This is a "PTAN" identifier . This identifiers is of the category "OTHER".




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