Provider Demographics
NPI:1326128158
Name:MAINSTREET MEDICAL PRACTICE
Entity Type:Organization
Organization Name:MAINSTREET MEDICAL PRACTICE
Other - Org Name:DEBORAH B PENROSE DO GISELA F SCHECTER MD PAMELA CARRINGTON DO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:B
Authorized Official - Last Name:PENROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:650-726-1200
Mailing Address - Street 1:725 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:HALF MOON BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94019
Mailing Address - Country:US
Mailing Address - Phone:650-726-1200
Mailing Address - Fax:650-726-1235
Practice Address - Street 1:725 MAIN STREET
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019
Practice Address - Country:US
Practice Address - Phone:650-726-1200
Practice Address - Fax:650-726-1235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A4678207Q00000X
CA20A62160207Q00000X
CAG31635207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E08803Medicare UPIN
A89510Medicare UPIN
020A46780Medicare ID - Type Unspecified
F59797Medicare UPIN
00G316350Medicare ID - Type Unspecified