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General NPI Number Information
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NPI Number | 1619155306
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Entity Type | Organization
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Legal Business Name | MAIN STREET INTERNAL MEDICINE & PEDIATRICS PC
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Dates
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Enumeration Date | 02/05/2008
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Last Update Date | 01/22/2009
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Provider Practice Location Address
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Address Line | 401 S MAIN ST SUITE C5
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City | ALPHARETTA
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State | GA
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Zip | 30009-7960
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Country | US
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Telephone | 678-205-2437
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Fax | 678-205-2439
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Provider Business Mailing Address
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Address Line | 401 S MAIN ST SUITE C5
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City | ALPHARETTA
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State | GA
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Zip | 30009-7960
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Country | US
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Telephone | 678-205-2437
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Fax | 678-205-2439
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. MARIBEL LABINDALAWA ANGKA SERVERA
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Credential | MD
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Telephone | 678-205-2437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 047657
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 047388
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License Number State | GA
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