Provider Demographics
NPI:1902281686
Name:MEDEXPRESS URGENT CARE, INC - WEST VIRGINIA
Entity Type:Organization
Organization Name:MEDEXPRESS URGENT CARE, INC - WEST VIRGINIA
Other - Org Name:MEDEXPRESS URGENT CARE - FAYETTEVILLE, MAPLE LN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-349-6740
Mailing Address - Street 1:423 FORTRESS BLVD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-1351
Mailing Address - Country:US
Mailing Address - Phone:304-225-2500
Mailing Address - Fax:304-985-6350
Practice Address - Street 1:5447 MAPLE LN
Practice Address - Street 2:SUITE B
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-6872
Practice Address - Country:US
Practice Address - Phone:304-658-9397
Practice Address - Fax:304-658-9396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-23
Last Update Date:2024-04-09
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
WV01612OtherSTATE LICENSE
WV3910007110Medicaid
WV9384131Medicare PIN
WV01612OtherSTATE LICENSE