Provider Demographics
NPI:1093864035
Name:MAIN STREET FAMILY PRACTICE INC
Entity Type:Organization
Organization Name:MAIN STREET FAMILY PRACTICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:FUJIMURA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-836-5171
Mailing Address - Street 1:9000 NORTH MAIN STREET
Mailing Address - Street 2:SUITE 403
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-1180
Mailing Address - Country:US
Mailing Address - Phone:937-836-5171
Mailing Address - Fax:937-832-0728
Practice Address - Street 1:9000 NORTH MAIN STREET
Practice Address - Street 2:SUITE 403
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-1180
Practice Address - Country:US
Practice Address - Phone:937-836-5171
Practice Address - Fax:937-832-0728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000013156OtherANTHEM BCBS
OH0668433Medicaid
00000013156OtherANTHEM BCBS
OH6393000001Medicare NSC
00000013156OtherANTHEM BCBS