Provider Demographics
NPI:1598739526
Name:MAIN STREET FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:MAIN STREET FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:TIERNEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:781-662-4934
Mailing Address - Street 1:675 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-3138
Mailing Address - Country:US
Mailing Address - Phone:781-662-4934
Mailing Address - Fax:781-662-4711
Practice Address - Street 1:675 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3138
Practice Address - Country:US
Practice Address - Phone:781-662-4934
Practice Address - Fax:781-662-4711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM20917Medicare ID - Type Unspecified