Provider Demographics
NPI: | 1013440593 |
---|---|
Name: | TOTAL ACCESS URGENT CARE, PC |
Entity Type: | Organization |
Organization Name: | TOTAL ACCESS URGENT CARE, PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | MATTHEW |
Authorized Official - Middle Name: | M |
Authorized Official - Last Name: | BRUCKEL |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 131-423-8660 |
Mailing Address - Street 1: | 13861 MANCHESTER RD |
Mailing Address - Street 2: | |
Mailing Address - City: | BALLWIN |
Mailing Address - State: | MO |
Mailing Address - Zip Code: | 63011-4503 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 314-238-4660 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3114 S GRAND BLVD |
Practice Address - Street 2: | |
Practice Address - City: | SAINT LOUIS |
Practice Address - State: | MO |
Practice Address - Zip Code: | 63118-1012 |
Practice Address - Country: | US |
Practice Address - Phone: | 131-496-1225 |
Practice Address - Fax: | 314-270-3694 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-04-11 |
Last Update Date: | 2017-04-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QU0200X | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
000015584 | Medicare PIN |