Provider Demographics
NPI:1790497444
Name:MAIN STREET MEDICAL PROVIDERS LLC
Entity Type:Organization
Organization Name:MAIN STREET MEDICAL PROVIDERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANTHOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAKILAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:551-223-7912
Mailing Address - Street 1:65 LEAH WAY
Mailing Address - Street 2:
Mailing Address - City:PARSIPPANY
Mailing Address - State:NJ
Mailing Address - Zip Code:07054-3448
Mailing Address - Country:US
Mailing Address - Phone:551-223-7912
Mailing Address - Fax:646-701-5598
Practice Address - Street 1:65 LEAH WAY
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-3448
Practice Address - Country:US
Practice Address - Phone:551-223-7912
Practice Address - Fax:646-701-5598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA09915600OtherLICENSE