Provider Demographics
NPI:1467510008
Name:MAIN STREET FAMILY MEDICINE, PA
Entity Type:Organization
Organization Name:MAIN STREET FAMILY MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:D
Authorized Official - Last Name:CRANE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-561-2518
Mailing Address - Street 1:111 VINE ST
Mailing Address - Street 2:
Mailing Address - City:HAMMONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08037-1447
Mailing Address - Country:US
Mailing Address - Phone:609-561-2518
Mailing Address - Fax:
Practice Address - Street 1:111 VINE ST
Practice Address - Street 2:
Practice Address - City:HAMMONTON
Practice Address - State:NJ
Practice Address - Zip Code:08037-1447
Practice Address - Country:US
Practice Address - Phone:609-561-2518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB42970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3411001Medicaid
NJ3411001Medicaid