Healthcare Provider Details

I. General information

NPI: 1003039033
Provider Name (Legal Business Name): MAIN ST MEDICAL USA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11734 NORTH DALE MABRY
TAMPA FL
33618
US

IV. Provider business mailing address

11734 NORTH DALE MABRY
TAMPA FL
33618
US

V. Phone/Fax

Practice location:
  • Phone: 813-968-6000
  • Fax: 813-968-6007
Mailing address:
  • Phone: 813-968-6000
  • Fax: 813-968-6007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN ALLEN STEFANO
Title or Position: DIRECTOR MD
Credential: MD
Phone: 813-968-6000