Provider Demographics
NPI:1053691311
Name:EXPRESS MEDICAL, LLC
Entity type:Organization
Organization Name:EXPRESS MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:WT
Authorized Official - Last Name:PHILIP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-263-6713
Mailing Address - Street 1:931 LOWER FAYETTEVILLE RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-5790
Mailing Address - Country:US
Mailing Address - Phone:770-715-9391
Mailing Address - Fax:
Practice Address - Street 1:931 LOWER FAYETTEVILLE RD
Practice Address - Street 2:SUITE J
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-5790
Practice Address - Country:US
Practice Address - Phone:770-715-9391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-18
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA142462261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care