MEDICARE: MAIN STREET MEDICAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	20A6216	CA

General Provider Information

NPI Number	:	1023488970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN STREET MEDICAL

Provider Business Mailing Address
First Line	:	799 MAIN ST
Second Line	:	SUITE D
City	:	HALF MOON BAY
State	:	CA
Zip	:	94019-1996
Country	:	US
Telephone Number	:	650-726-1200
Fax Number	:	650-726-1236

Provider Business Practice Location Address
First Line	:	799 MAIN ST
Second Line	:	SUITE D
City	:	HALF MOON BAY
State	:	CA
Zip	:	94019-1996
Country	:	US
Telephone Number	:	650-726-1200
Fax Number	:	650-726-1236

Authorized Official
Title or Position	:	PHYSICIAN/OWNER
Name	:	DR. PAMELA CELESTE CARRINGTON-TRIBBLE
Credential	:	D.O.
Telephone Number	:	650-726-1200

Provider Enumeration Date	:	10/05/2015
Last Update Date	:	10/05/2015

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Directions to “MAIN STREET MEDICAL ” Practice Location

Language	Start Address	Practice Location

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