=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033489281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | URGENT CARE, INC - WEST VIRGINIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2012
-----------------------------------------------------
Last Update Date | 05/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 GRAND CENTRAL AVE SUITE 115
-----------------------------------------------------
City | VIENNA
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26105-1079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-485-3627
-----------------------------------------------------
Fax | 304-295-2315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 423 FORTRESS BLVD
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26508-1351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-225-2500
-----------------------------------------------------
Fax | 724-743-1133
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CONTRACTING
-----------------------------------------------------
Name | JASON GALLAGHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-225-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------