Provider Demographics
NPI:1801849427
Name:MAIN STREET ASC LLC
Entity Type:Organization
Organization Name:MAIN STREET ASC LLC
Other - Org Name:OPHTHALMIC ASSOCIATES SURGERY AND LASER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT GOVERNING BODY
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:POLITO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-266-5795
Mailing Address - Street 1:1318 EISENHOWER BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904-3307
Mailing Address - Country:US
Mailing Address - Phone:814-266-5795
Mailing Address - Fax:814-266-5793
Practice Address - Street 1:1318 EISENHOWER BLVD
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-3307
Practice Address - Country:US
Practice Address - Phone:814-536-5343
Practice Address - Fax:814-536-1525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAPPLIED261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical