=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275384174
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDEXPRESS URGENT CARE, P.C. - INDIANA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2024
-----------------------------------------------------
Last Update Date | 03/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 MAIN STREET
-----------------------------------------------------
City | TELL CITY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47586-2305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-608-4697
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 423 FORTRESS BLVD
-----------------------------------------------------
City | MORGANTOWN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26508-1351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-225-2500
-----------------------------------------------------
Fax | 304-985-6350
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DAVID FERRELL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 305-225-2500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------