Basic Information
| Provider Information | |||||||||
| NPI: | 1609063916 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAIN STREET MEDCENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 951 MOUNT HERMON RD STE A | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218045159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105482700 | ||||||||
| FaxNumber: | 4105482608 | ||||||||
| Practice Location | |||||||||
| Address1: | 951 MOUNT HERMON RD STE A | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218045159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105482700 | ||||||||
| FaxNumber: | 4105482608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 10/11/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURNS | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | ELLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4105482700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | CRNP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | HOO36690 | MD | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.