Healthcare Provider Details

I. General information

NPI: 1245693977
Provider Name (Legal Business Name): MEDEXPRESS URGENT CARE ILLINOIS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 HOMER M ADAMS PARKWAY
ALTON IL
62002-5603
US

IV. Provider business mailing address

1001 CONSOL ENERGY DR
CANONSBURG PA
15317-6506
US

V. Phone/Fax

Practice location:
  • Phone: 618-465-0260
  • Fax: 618-465-0250
Mailing address:
  • Phone: 304-225-2500
  • Fax: 724-743-1133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: TIM BUGIN
Title or Position: VP PAYOR CONTRACTING
Credential:
Phone: 304-225-2500