=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801849427
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAIN STREET ASC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2006
-----------------------------------------------------
Last Update Date | 04/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1318 EISENHOWER BLVD
-----------------------------------------------------
City | JOHNSTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15904-3307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-536-5343
-----------------------------------------------------
Fax | 814-536-1525
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1318 EISENHOWER BOULEVARD
-----------------------------------------------------
City | JOHNSTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15904-3307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-266-5795
-----------------------------------------------------
Fax | 814-266-5793
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT GOVERNING BODY
-----------------------------------------------------
Name | DR. JOSEPH R POLITO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 814-266-5795
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | APPLIED
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------