Provider Demographics
NPI:1003039033
Name:MAIN ST MEDICAL USA
Entity type:Organization
Organization Name:MAIN ST MEDICAL USA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR MD
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:STEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-968-6000
Mailing Address - Street 1:11734 NORTH DALE MABRY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618
Mailing Address - Country:US
Mailing Address - Phone:813-968-6000
Mailing Address - Fax:813-968-6007
Practice Address - Street 1:11734 NORTH DALE MABRY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618
Practice Address - Country:US
Practice Address - Phone:813-968-6000
Practice Address - Fax:813-968-6007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty