Healthcare Provider Details

I. General information

NPI: 1306812003
Provider Name (Legal Business Name): MAIN STREET MEDICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 12/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5645 MAIN ST
FLUSHING NY
11355-5045
US

IV. Provider business mailing address

PO BOX 27842
NEW YORK NY
10087-7842
US

V. Phone/Fax

Practice location:
  • Phone: 718-670-1234
  • Fax:
Mailing address:
  • Phone: 718-661-8711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DORA HARTOFILIS
Title or Position: ACTING DIRECTOR, BILLING
Credential:
Phone: 718-661-8711