Healthcare Provider Details

I. General information

NPI: 1043832769
Provider Name (Legal Business Name): MAIN STREET MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2020
Last Update Date: 05/04/2021
Certification Date: 05/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 REGENCY PARK STE 7
O FALLON IL
62269-1994
US

IV. Provider business mailing address

2250 E GERMANN RD STE 8
CHANDLER AZ
85286-1575
US

V. Phone/Fax

Practice location:
  • Phone: 480-926-2260
  • Fax:
Mailing address:
  • Phone: 480-926-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ELLIE DESCALZO
Title or Position: CREDENTIALING OFFICER
Credential:
Phone: 480-926-7800