MEDICARE: MAIN STREET MEDICAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1013340892
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN STREET MEDICAL, LLC

Provider Business Mailing Address
First Line	:	106 W MAIN ST
Second Line	:
City	:	LOUISVILLE
State	:	MS
Zip	:	39339-2620
Country	:	US
Telephone Number	:	662-803-5318
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 W MAIN ST
Second Line	:
City	:	LOUISVILLE
State	:	MS
Zip	:	39339-2620
Country	:	US
Telephone Number	:	662-803-5318
Fax Number	:

Authorized Official
Title or Position	:	FAMILY NURSE PRACTITIONER
Name	:	EMILY DAVIS PERKINS
Credential	:
Telephone Number	:	662-803-5318

Provider Enumeration Date	:	08/15/2013
Last Update Date	:	08/16/2013

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Directions to “MAIN STREET MEDICAL, LLC ” Practice Location

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