Provider Demographics
NPI:1801102215
Name:EXPRESS MEDICAL CARE, LLC
Entity type:Organization
Organization Name:EXPRESS MEDICAL CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAZLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-236-6000
Mailing Address - Street 1:5031 N ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-3453
Mailing Address - Country:US
Mailing Address - Phone:618-212-6800
Mailing Address - Fax:618-212-6820
Practice Address - Street 1:5031 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-3453
Practice Address - Country:US
Practice Address - Phone:618-212-6800
Practice Address - Fax:618-212-6820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-23
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6471700001Medicare NSC