MEDICARE: JEFFERSON URGENT CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory		WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538230982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFFERSON URGENT CARE, LLC

Provider Business Mailing Address
First Line	:	84 SOMERSET BLVD
Second Line	:
City	:	CHARLES TOWN
State	:	WV
Zip	:	25414-4827
Country	:	US
Telephone Number	:	304-728-8543
Fax Number	:	304-728-8644

Provider Business Practice Location Address
First Line	:	84 SOMERSET BLVD
Second Line	:
City	:	CHARLES TOWN
State	:	WV
Zip	:	25414-4827
Country	:	US
Telephone Number	:	304-728-8543
Fax Number	:	304-728-8644

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MR. DUANE C BAILEY
Credential	:
Telephone Number	:	304-728-8543

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	08/22/2020

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