Provider Demographics
NPI:1386837763
Name:MAIN STREET FAMILY MEDICAL, INC.
Entity Type:Organization
Organization Name:MAIN STREET FAMILY MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-348-7100
Mailing Address - Street 1:500 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-2727
Mailing Address - Country:US
Mailing Address - Phone:192-834-8710
Mailing Address - Fax:928-348-7813
Practice Address - Street 1:500 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-2727
Practice Address - Country:US
Practice Address - Phone:192-834-8710
Practice Address - Fax:928-348-7813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ104331Medicare PIN