Provider Demographics
NPI:1063683662
Name:MAIN STREET MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:MAIN STREET MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SCHWARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-946-4662
Mailing Address - Street 1:36001 EUCLID AVE
Mailing Address - Street 2:C-17
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-4643
Mailing Address - Country:US
Mailing Address - Phone:440-946-4662
Mailing Address - Fax:440-946-4084
Practice Address - Street 1:7190 COTTESMORE LN
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-4702
Practice Address - Country:US
Practice Address - Phone:440-349-1983
Practice Address - Fax:440-349-1983
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-0015207R00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2817321Medicaid
OH000000562822OtherANTHEM BLUE SHIELD
OH9375531Medicare PIN
OH000000562822OtherANTHEM BLUE SHIELD