Provider Demographics
NPI:1457176695
Name:MAIN STREET PRIMARY CARE & AESTHETICS, PLLC
Entity type:Organization
Organization Name:MAIN STREET PRIMARY CARE & AESTHETICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER (PENDING)
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GIFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:606-584-5658
Mailing Address - Street 1:870 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-9604
Mailing Address - Country:US
Mailing Address - Phone:606-584-5658
Mailing Address - Fax:
Practice Address - Street 1:2003 OLD MAIN ST
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-8928
Practice Address - Country:US
Practice Address - Phone:606-759-7878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty