Provider Demographics
NPI:1336633510
Name:MEDEXPRESS PRIMARY CARE SOUTH CAROLINA, P.C.
Entity Type:Organization
Organization Name:MEDEXPRESS PRIMARY CARE SOUTH CAROLINA, P.C.
Other - Org Name:ANDERSON MICHELIN FAMILY HEALTH CENTER
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:724-743-1133
Practice Address - Street 1:10 BIB WAY
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29626
Practice Address - Country:US
Practice Address - Phone:864-332-1793
Practice Address - Fax:864-332-1798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty