Provider Demographics
NPI:1427194927
Name:MAIN STREET FAMILY MEDICINE P C
Entity Type:Organization
Organization Name:MAIN STREET FAMILY MEDICINE P C
Other - Org Name:MAIN CENTER FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:248-348-1131
Mailing Address - Street 1:422 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1224
Mailing Address - Country:US
Mailing Address - Phone:248-348-1131
Mailing Address - Fax:248-348-1170
Practice Address - Street 1:422 N CENTER ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1224
Practice Address - Country:US
Practice Address - Phone:248-348-1131
Practice Address - Fax:248-348-1170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4118116Medicaid
MICG4894OtherMEDICARE RAILROAD PIN
MI4118116Medicaid