=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609209048
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDEXPRESS URGENT CARE - NORTHERN NEW JERSEY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2013
-----------------------------------------------------
Last Update Date | 01/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1569 US HIGHWAY 22
-----------------------------------------------------
City | WATCHUNG
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07069-6507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-322-2631
-----------------------------------------------------
Fax | 908-322-2679
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 CONSOL ENERGY DR
-----------------------------------------------------
City | CANONSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15317-6506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-225-2500
-----------------------------------------------------
Fax | 724-743-1133
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR PAYOR CONTRACTING
-----------------------------------------------------
Name | BRETT GALL
-----------------------------------------------------
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 |
-----------------------------------------------------