Provider Demographics
NPI:1760489629
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:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:G
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-857-8769
Mailing Address - Street 1:302 S MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CHINA GROVE
Mailing Address - State:NC
Mailing Address - Zip Code:28023
Mailing Address - Country:US
Mailing Address - Phone:704-857-8769
Mailing Address - Fax:704-857-8779
Practice Address - Street 1:302 S MAIN STREET
Practice Address - Street 2:
Practice Address - City:CHINA GROVE
Practice Address - State:NC
Practice Address - Zip Code:28023
Practice Address - Country:US
Practice Address - Phone:704-857-8769
Practice Address - Fax:704-857-8779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89011UHMedicaid
NCS77831Medicare PIN
NCS77831Medicare UPIN
NC89011UHMedicaid