Basic Information
| Provider Information | |||||||||
| NPI: | 1164493482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAIN STREET MED CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 951A MOUNT HERMON RD | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218045105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105482700 | ||||||||
| FaxNumber: | 4105482608 | ||||||||
| Practice Location | |||||||||
| Address1: | 951A MOUNT HERMON RD | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218045105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105482700 | ||||||||
| FaxNumber: | 4105482608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BURNS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | ONEIL | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR CO OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4105482700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M36690 | MD | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | W0520001 | 01 | DC | BLUE CHOICE | OTHER | LL15MA | 01 | BLUE SHIELD | OTHER |