Provider Demographics
NPI:1922499060
Name:MAIN STREET MEDICAL GROUP LLC
Entity type:Organization
Organization Name:MAIN STREET MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMIERI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-335-5140
Mailing Address - Street 1:199 MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KEANSBURG
Mailing Address - State:NJ
Mailing Address - Zip Code:07734-1768
Mailing Address - Country:US
Mailing Address - Phone:732-787-3456
Mailing Address - Fax:888-251-1086
Practice Address - Street 1:199 MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:KEANSBURG
Practice Address - State:NJ
Practice Address - Zip Code:07734-1768
Practice Address - Country:US
Practice Address - Phone:732-787-3456
Practice Address - Fax:888-251-1086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty