Provider Demographics
NPI:1346570389
Name:MAIN STREET MEDICAL CLINIC
Entity Type:Organization
Organization Name:MAIN STREET MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:OMOSALEWA
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNDIPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-413-8258
Mailing Address - Street 1:10802 E. MAIN STREET,
Mailing Address - Street 2:STE. B
Mailing Address - City:THONOTOSSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:33592
Mailing Address - Country:US
Mailing Address - Phone:813-413-8258
Mailing Address - Fax:813-413-8310
Practice Address - Street 1:10802 E. MAIN ST
Practice Address - Street 2:STE B
Practice Address - City:THONOTOSASSA
Practice Address - State:FL
Practice Address - Zip Code:33592-2840
Practice Address - Country:US
Practice Address - Phone:813-413-8258
Practice Address - Fax:813-413-8310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty