Provider Demographics
NPI:1114437589
Name:DWIC OF TAMPA BAY, INC.
Entity Type:Organization
Organization Name:DWIC OF TAMPA BAY, INC.
Other - Org Name:MEDEXPRESS URGENT CARE - ESTERO, S TAMIAMI TRL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PAYOR CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:GALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-225-2500
Mailing Address - Street 1:1001 CONSOL ENERGY DR
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-6506
Mailing Address - Country:US
Mailing Address - Phone:304-225-2500
Mailing Address - Fax:
Practice Address - Street 1:19985 S TAMIAMI TRAIL
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-2268
Practice Address - Country:US
Practice Address - Phone:239-495-3317
Practice Address - Fax:239-495-3329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty