Provider Demographics
NPI:1285655381
Name:MAIN STREET MEDICAL ASSOCIATES P C
Entity Type:Organization
Organization Name:MAIN STREET MEDICAL ASSOCIATES P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:LYNN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-547-4536
Mailing Address - Street 1:525 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:PA
Mailing Address - Zip Code:15666-1833
Mailing Address - Country:US
Mailing Address - Phone:724-547-4536
Mailing Address - Fax:724-547-3799
Practice Address - Street 1:525 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:PA
Practice Address - Zip Code:15666-1833
Practice Address - Country:US
Practice Address - Phone:724-547-4536
Practice Address - Fax:724-547-3799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012524207Q00000X
PAMD434385207Q00000X
PAMD017110E207R00000X
PAMD037152L207R00000X
PAMD030863E207RC0000X
PAMA051424363A00000X
PASP010951363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0655146Medicaid
PA0655146Medicaid
=========OtherTAX ID NUMBER