Provider Demographics
NPI:1972706612
Name:MAIN STREET FAMILY PRACTICE PC
Entity type:Organization
Organization Name:MAIN STREET FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONWER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:LOUIS
Authorized Official - Suffix:
Authorized Official - Credentials:CFNP
Authorized Official - Phone:989-343-1367
Mailing Address - Street 1:117 S BURGESS ST
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-1403
Mailing Address - Country:US
Mailing Address - Phone:989-343-1367
Mailing Address - Fax:989-343-1427
Practice Address - Street 1:117 S BURGESS ST
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-1403
Practice Address - Country:US
Practice Address - Phone:989-343-1367
Practice Address - Fax:989-343-1427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4627355Medicaid
MI5008703250OtherBCBSM
MI4627355Medicaid
MIP24689Medicare UPIN