Provider Demographics
NPI:1316398118
Name:DWIC OF TAMPA BAY, INC
Entity Type:Organization
Organization Name:DWIC OF TAMPA BAY, INC
Other - Org Name:MEDEXPRESS URGENT CARE - FORT MYERS, S CLEVELAND AVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP PAYOR CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
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 1:12375 S CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3803
Practice Address - Country:US
Practice Address - Phone:239-936-2013
Practice Address - Fax:239-275-1041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-23
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020260000Medicaid
FL020260000Medicaid