Provider Demographics
NPI:1598477887
Name:MAINE STREET MEDICAL PLLC
Entity Type:Organization
Organization Name:MAINE STREET MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREAS
Authorized Official - Middle Name:
Authorized Official - Last Name:THYSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-249-9759
Mailing Address - Street 1:22 DIONNE CIR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-3211
Mailing Address - Country:US
Mailing Address - Phone:314-249-9759
Mailing Address - Fax:
Practice Address - Street 1:8 MASON ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-1514
Practice Address - Country:US
Practice Address - Phone:314-249-9759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-19
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty