Provider Demographics
NPI:1407807787
Name:MAIN STREET MEDICAL CENTER, PC
Entity Type:Organization
Organization Name:MAIN STREET MEDICAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BONITO
Authorized Official - Middle Name:Y
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-418-0004
Mailing Address - Street 1:186 N MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MILLTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08850-1418
Mailing Address - Country:US
Mailing Address - Phone:732-418-0004
Mailing Address - Fax:732-545-1185
Practice Address - Street 1:186 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:MILLTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08850-1418
Practice Address - Country:US
Practice Address - Phone:732-418-0004
Practice Address - Fax:732-545-1185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03262900111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0900XChiropractic ProvidersChiropractorInternistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ092344Medicare NSC