Provider Demographics
NPI:1215372586
Name:MEDEXPRESS URGENT CARE PC - INDIANA
Entity Type:Organization
Organization Name:MEDEXPRESS URGENT CARE PC - INDIANA
Other - Org Name:MEDEXPRESS URGENT CARE - SOUTHPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF PAYOR CONTRACTING
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:G
Authorized Official - Last Name:BUGIN
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:724-743-1133
Practice Address - Street 1:7225 US 31 S
Practice Address - Street 2:SUITE G
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-8685
Practice Address - Country:US
Practice Address - Phone:317-859-1156
Practice Address - Fax:317-859-1192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201134900GMedicaid
ININ1289Medicare PIN
IN201134900GMedicaid