Healthcare Provider Details

I. General information

NPI: 1487079505
Provider Name (Legal Business Name): MAIN STREET MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10549 N FLORIDA AVE STE A
TAMPA FL
33612-6707
US

IV. Provider business mailing address

PO BOX 17175
TAMPA FL
33682-7175
US

V. Phone/Fax

Practice location:
  • Phone: 813-220-1400
  • Fax: 813-440-6484
Mailing address:
  • Phone: 813-220-1400
  • Fax: 813-341-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. STEPHEN O BANJOKO
Title or Position: CFO
Credential:
Phone: 212-257-0225