Basic Information
| Provider Information | |||||||||
| NPI: | 1386711497 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 54 MAIN STREET MEDICAL PRACTICE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2965 LONG BEACH RD | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115723255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165938953 | ||||||||
| FaxNumber: | 5162926287 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | HEMPSTEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115502412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165384531 | ||||||||
| FaxNumber: | 5162926287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 10/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | ADDES | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5165938953 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 10/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02757440 | 05 | NY | MEDICAID |