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General NPI Number Information
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NPI Number | 1912650607
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Entity Type | Organization
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Legal Business Name | MEDEXPRESS PRIMARY CARE WISCONSIN, S.C.
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Dates
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Enumeration Date | 02/02/2022
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Last Update Date | 02/02/2022
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Provider Practice Location Address
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Address Line | 2020 INNOVATION CT
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City | DE PERE
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State | WI
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Zip | 54115-6009
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Country | US
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Telephone | 920-661-4215
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Fax | 920-661-4277
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Provider Business Mailing Address
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Address Line | 1001 CONSOL ENERGY DR
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City | CANONSBURG
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State | PA
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Zip | 15317-6506
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Country | US
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Telephone | 304-225-2500
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Fax | 724-743-1133
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Authorized Official
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Title or Position | DIRECTOR OF PAYOR CONTRACTING
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Name | BRETT GALL
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Credential |
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Telephone | 304-225-2500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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