=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619442837
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | QUALITY CARE ASSOCIATES URGENT CARE AND WELLNESS CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2018
-----------------------------------------------------
Last Update Date | 03/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 416 FRONT ST
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45750-2124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-516-6062
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 416 FRONT ST
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45750-2124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNT EXECUTIVE
-----------------------------------------------------
Name | JEFFERY PATEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 740-516-6062
-----------------------------------------------------
=====================================================
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 | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------