MEDICARE: MAIN STREET MEDICAL CLINIC, P.A.

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	208000000X	Pediatrics Physician	MC-2252	AR
2	207R00000X	Internal Medicine Physician	MC-2252	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841298791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN STREET MEDICAL CLINIC, P.A.

Provider Business Mailing Address
First Line	:	722 N MAIN ST
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72015-3337
Country	:	US
Telephone Number	:	501-315-0059
Fax Number	:	501-315-1320

Provider Business Practice Location Address
First Line	:	722 N MAIN ST
Second Line	:
City	:	BENTON
State	:	AR
Zip	:	72015-3337
Country	:	US
Telephone Number	:	501-315-0059
Fax Number	:	501-315-1320

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	SHERYL WILCHMAN
Credential	:
Telephone Number	:	501-315-0059

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	05/20/2021

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Directions to “MAIN STREET MEDICAL CLINIC, P.A. ” Practice Location

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