1366718926 NPI number — MEDEXPRESS URGENT CARE OF BOYNTON BEACH, LLC

Table of content: (NPI 1366718926)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366718926 NPI number — MEDEXPRESS URGENT CARE OF BOYNTON BEACH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDEXPRESS URGENT CARE OF BOYNTON BEACH, LLC
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 - PALM BEACH GARDENS
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:
1366718926
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 CONSOL ENERGY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANONSBURG
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15317-6506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-225-2500
Provider Business Mailing Address Fax Number:
724-743-1133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4520 DONALD ROSS RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PALM BEACH GARDENS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33418-5105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-776-3090
Provider Business Practice Location Address Fax Number:
561-296-8141
Provider Enumeration Date:
03/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BUGIN
Authorized Official First Name:
TIM
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF PAYOR CONTRACTING
Authorized Official Telephone Number:
304-225-2500

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X , with the licence number: HCC8240 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000280900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com