Healthcare Provider Details

I. General information

NPI: 1841298791
Provider Name (Legal Business Name): MAIN STREET MEDICAL CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 N MAIN ST
BENTON AR
72015-3337
US

IV. Provider business mailing address

722 N MAIN ST
BENTON AR
72015-3337
US

V. Phone/Fax

Practice location:
  • Phone: 501-315-0059
  • Fax: 501-315-1320
Mailing address:
  • Phone: 501-315-0059
  • Fax: 501-315-1320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMC-2252
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMC-2252
License Number StateAR

VIII. Authorized Official

Name: SHERYL WILCHMAN
Title or Position: OFFICE MANAGER
Credential:
Phone: 501-315-0059