Provider Demographics
NPI:1811983943
Name:MAIN STREET FAMILY PRACTICE
Entity type:Organization
Organization Name:MAIN STREET FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:CLEMENTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-223-9335
Mailing Address - Street 1:190 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-4349
Mailing Address - Country:US
Mailing Address - Phone:724-223-9335
Mailing Address - Fax:724-223-0310
Practice Address - Street 1:190 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-4349
Practice Address - Country:US
Practice Address - Phone:724-223-9335
Practice Address - Fax:724-223-0310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020154E207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty