Provider Demographics
NPI:1700335080
Name:MEDEXPRESS URGENT CARE ILLINOIS, PC
Entity Type:Organization
Organization Name:MEDEXPRESS URGENT CARE ILLINOIS, PC
Other - Org Name:MEDEXPRESS URGENT CARE - O'FALLON, W HIGHWAY 50
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 1:1711 W HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1681
Practice Address - Country:US
Practice Address - Phone:618-628-1791
Practice Address - Fax:618-628-1795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-27
Last Update Date:2017-03-24
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
IL7525180006Medicare NSC
ILF100284964Medicare PIN