Provider Demographics
NPI:1316227838
Name:MEDEXPRESS URGENT CARE, INC. - WEST VIRGINIA
Entity Type:Organization
Organization Name:MEDEXPRESS URGENT CARE, INC. - WEST VIRGINIA
Other - Org Name:MEDEXPRESS URGENT CARE - BRIDGEPORT JERRY DOVE DRIVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-349-6740
Mailing Address - Street 1:423 FORTRESS BLVD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-1351
Mailing Address - Country:US
Mailing Address - Phone:304-225-2500
Mailing Address - Fax:304-985-6350
Practice Address - Street 1:120 MEDICAL PARK DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330
Practice Address - Country:US
Practice Address - Phone:304-842-3278
Practice Address - Fax:304-842-6716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-29
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01612207P00000X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV01612OtherSTATE LICENSE
WV3810021540Medicaid
WV6276490013Medicare NSC
WV01612OtherSTATE LICENSE
WV9384131Medicare PIN