Provider Demographics
NPI:1093217846
Name:MAIN STREET CLINIC
Entity Type:Organization
Organization Name:MAIN STREET CLINIC
Other - Org Name:WELLS MEDICAL SERVICES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:M.D/CEO-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREENMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:260-824-9265
Mailing Address - Street 1:117 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-2047
Mailing Address - Country:US
Mailing Address - Phone:260-824-9265
Mailing Address - Fax:
Practice Address - Street 1:117 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-2047
Practice Address - Country:US
Practice Address - Phone:260-824-9265
Practice Address - Fax:260-824-9267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034958207Q00000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100101710AMedicaid