Provider Demographics
NPI:1417230129
Name:MAIN STREET MEDICAL, PLLC
Entity Type:Organization
Organization Name:MAIN STREET MEDICAL, PLLC
Other - Org Name:MAIN STREET MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED USER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-521-5404
Mailing Address - Street 1:326 CREEKSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SIGNAL MTN
Mailing Address - State:TN
Mailing Address - Zip Code:37377-2086
Mailing Address - Country:US
Mailing Address - Phone:423-243-8196
Mailing Address - Fax:417-429-2893
Practice Address - Street 1:1667 OOLTEWAH RINGGOLD RD
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-9830
Practice Address - Country:US
Practice Address - Phone:423-886-7545
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty