Provider Demographics
NPI:1164493482
Name:MAIN STREET MED CENTER LLC
Entity Type:Organization
Organization Name:MAIN STREET MED CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR CO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ONEIL
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:410-548-2700
Mailing Address - Street 1:951A MOUNT HERMON RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5105
Mailing Address - Country:US
Mailing Address - Phone:410-548-2700
Mailing Address - Fax:410-548-2608
Practice Address - Street 1:951A MOUNT HERMON RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5105
Practice Address - Country:US
Practice Address - Phone:410-548-2700
Practice Address - Fax:410-548-2608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM36690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCW0520001OtherBLUE CHOICE
LL15MAOtherBLUE SHIELD
MD=========OtherBLUE SHIELD
MD=========OtherBLUE SHIELD
DCW0520001OtherBLUE CHOICE