Provider Demographics
NPI:1306812003
Name:MAIN STREET MEDICAL, PC
Entity type:Organization
Organization Name:MAIN STREET MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACTING DIRECTOR, BILLING
Authorized Official - Prefix:
Authorized Official - First Name:DORA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTOFILIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-661-8711
Mailing Address - Street 1:PO BOX 27842
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-7842
Mailing Address - Country:US
Mailing Address - Phone:718-661-8711
Mailing Address - Fax:
Practice Address - Street 1:5645 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5045
Practice Address - Country:US
Practice Address - Phone:718-670-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01115737Medicaid
NY00780Medicare ID - Type Unspecified