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General NPI Number Information
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NPI Number | 1073542809
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Entity Type | Organization
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Legal Business Name | MAIN STREET FAMILY PRACTICE, INC
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Dates
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Enumeration Date | 07/02/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 533 MAIN ST
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City | LOGAN
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State | WV
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Zip | 25601-3809
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Country | US
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Telephone | 304-752-3400
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Fax | 304-752-8138
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Provider Business Mailing Address
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Address Line | 533 MAIN ST
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City | LOGAN
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State | WV
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Zip | 25601-3809
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Country | US
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Telephone | 304-752-3400
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Fax | 304-752-8138
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Authorized Official
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Title or Position | PRESIDENT
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Name | KENNETH SELLS
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Credential | DO
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Telephone | 304-752-3400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 016632
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License Number State | WV
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