Provider Demographics
NPI:1841298791
Name:MAIN STREET MEDICAL CLINIC, P.A.
Entity type:Organization
Organization Name:MAIN STREET MEDICAL CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-315-0059
Mailing Address - Street 1:722 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3337
Mailing Address - Country:US
Mailing Address - Phone:501-315-0059
Mailing Address - Fax:501-315-1320
Practice Address - Street 1:722 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3337
Practice Address - Country:US
Practice Address - Phone:501-315-0059
Practice Address - Fax:501-315-1320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC-2252208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150521002Medicaid
AR150521002Medicaid