Healthcare Provider Details

I. General information

NPI: 1386711497
Provider Name (Legal Business Name): 54 MAIN STREET MEDICAL PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 JACKSON ST
HEMPSTEAD NY
11550-2412
US

IV. Provider business mailing address

2965 LONG BEACH RD
OCEANSIDE NY
11572-3255
US

V. Phone/Fax

Practice location:
  • Phone: 516-538-4531
  • Fax: 516-292-6287
Mailing address:
  • Phone: 516-593-8953
  • Fax: 516-292-6287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD ADDES
Title or Position: OWNER
Credential: DO
Phone: 516-593-8953