1104251958 NPI number — MEDEXPRESS URGENT CARE - NEW JERSEY, INC

Table of content: (NPI 1104251958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104251958 NPI number — MEDEXPRESS URGENT CARE - NEW JERSEY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDEXPRESS URGENT CARE - NEW JERSEY, INC
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:
6
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:
1104251958
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2016
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:
475 HURFFVILLE CROSSKEYS RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
SEWELL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08080-2320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-582-3426
Provider Business Practice Location Address Fax Number:
856-582-3427
Provider Enumeration Date:
09/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BUGIN
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
VP OF PAYOR CONTRACTING
Authorized Official Telephone Number:
302-225-2500

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: 0347116 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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