Healthcare Provider Details

I. General information

NPI: 1093217846
Provider Name (Legal Business Name): MAIN STREET CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 S MAIN ST
BLUFFTON IN
46714-2047
US

IV. Provider business mailing address

117 S MAIN ST
BLUFFTON IN
46714-2047
US

V. Phone/Fax

Practice location:
  • Phone: 260-824-9265
  • Fax: 260-824-9267
Mailing address:
  • Phone: 260-824-9265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01034958
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number01034958
License Number StateIN

VIII. Authorized Official

Name: JOHN J. GREENMAN
Title or Position: M.D/CEO-PRESIDENT
Credential: M.D.
Phone: 260-824-9265