Healthcare Provider Details

I. General information

NPI: 1063683662
Provider Name (Legal Business Name): MAIN STREET MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2008
Last Update Date: 08/18/2023
Certification Date: 08/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7190 COTTESMORE LN
SOLON OH
44139-4702
US

IV. Provider business mailing address

36001 EUCLID AVE C-17
WILLOUGHBY OH
44094-4643
US

V. Phone/Fax

Practice location:
  • Phone: 440-349-1983
  • Fax: 440-349-1983
Mailing address:
  • Phone: 440-946-4662
  • Fax: 440-946-4084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-06-0015
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDALL SCOTT SCHWARTZ
Title or Position: PROPRIETOR
Credential: M.D.
Phone: 440-946-4662