Provider Demographics
NPI:1083161640
Name:MEDEXPRESS URGENT CARE ILLINOIS, P.C,
Entity type:Organization
Organization Name:MEDEXPRESS URGENT CARE ILLINOIS, P.C,
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP PAYOR CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BUGIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-225-2500
Mailing Address - Street 1:1001 CONSOL ENERGY DR
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-6506
Mailing Address - Country:US
Mailing Address - Phone:304-225-2500
Mailing Address - Fax:724-743-1133
Practice Address - Street 1:211 GREENBRIAR DRIVE
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2287
Practice Address - Country:US
Practice Address - Phone:309-268-9807
Practice Address - Fax:309-268-9769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7525180005Medicare NSC
ILF100284964Medicare PIN