Provider Demographics
NPI:1609063916
Name:MAIN STREET MEDCENTER
Entity Type:Organization
Organization Name:MAIN STREET MEDCENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:410-548-2700
Mailing Address - Street 1:951 MOUNT HERMON RD STE A
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5159
Mailing Address - Country:US
Mailing Address - Phone:410-548-2700
Mailing Address - Fax:410-548-2608
Practice Address - Street 1:951 MOUNT HERMON RD STE A
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5159
Practice Address - Country:US
Practice Address - Phone:410-548-2700
Practice Address - Fax:410-548-2608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDHOO36690261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD772LMedicare PIN