Provider Demographics
NPI:1720511058
Name:MAINSTREET PEDIATRICS
Entity Type:Organization
Organization Name:MAINSTREET PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORRI
Authorized Official - Middle Name:M
Authorized Official - Last Name:PHIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:720-458-6543
Mailing Address - Street 1:9235 CROWN CREST BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80138-8880
Mailing Address - Country:US
Mailing Address - Phone:720-458-6543
Mailing Address - Fax:720-458-6544
Practice Address - Street 1:9235 CROWN CREST BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-8880
Practice Address - Country:US
Practice Address - Phone:720-458-6543
Practice Address - Fax:720-458-6544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0010267-NP208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty