Provider Demographics
NPI:1407889389
Name:MAIN ST. MED CARE PC
Entity Type:Organization
Organization Name:MAIN ST. MED CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAIRD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-447-6100
Mailing Address - Street 1:475 E MAIN ST
Mailing Address - Street 2:SUITE 103-105
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3121
Mailing Address - Country:US
Mailing Address - Phone:631-447-6100
Mailing Address - Fax:631-447-6126
Practice Address - Street 1:475 E MAIN ST
Practice Address - Street 2:SUITE 103-105
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3121
Practice Address - Country:US
Practice Address - Phone:631-447-6100
Practice Address - Fax:631-447-6126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04337Medicare PIN
NYW35712Medicare PIN
NYW35711Medicare ID - Type Unspecified