1205367802 NPI number — MEDEXPRESS URGENT CARE ILLINOIS, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205367802 NPI number — MEDEXPRESS URGENT CARE ILLINOIS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDEXPRESS URGENT CARE ILLINOIS, P.C.
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 - PEORIA, N BIG HOLLOW RD
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:
1205367802
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2017
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:
5038 N BIG HOLLOW ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61615-3510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-691-5690
Provider Business Practice Location Address Fax Number:
309-691-5687
Provider Enumeration Date:
03/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
GALL
Authorized Official First Name:
BRETT
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR PAYOR CONTRACTING
Authorized Official Telephone Number:
304-225-2500

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)





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