Provider Demographics
NPI:1205036738
Name:MAIN STREET MEDICAL CENTER, PLLC
Entity Type:Organization
Organization Name:MAIN STREET MEDICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ONEIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-372-8088
Mailing Address - Street 1:619 MAIN ST W
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25271-1107
Mailing Address - Country:US
Mailing Address - Phone:304-372-8088
Mailing Address - Fax:304-372-8609
Practice Address - Street 1:619 MAIN ST W
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:WV
Practice Address - Zip Code:25271-1107
Practice Address - Country:US
Practice Address - Phone:304-372-8088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2013207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty