1578099404 NPI number — MEDEXPRESS PRIMARY CARE MASSACHUSETTS, P.C.

Table of content: (NPI 1578099404)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578099404 NPI number — MEDEXPRESS PRIMARY CARE MASSACHUSETTS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDEXPRESS PRIMARY CARE MASSACHUSETTS, 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:
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:
1578099404
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2018
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:
578 HUNTINGTON AVE FL 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02115-5902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-879-5220
Provider Business Practice Location Address Fax Number:
724-743-1133
Provider Enumeration Date:
05/11/2017

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: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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