Organization
MAIN STREET MEDICAL LLC
Active
Other names
MAIN STREET MEDICAL CENTERS
Organization subpart
No
Provider details
NPI number
Authorized official
MR. STEPHEN O BANJOKO (CFO)
(212) 257-0225
Entity
Organization
Contact information
Practice address
10549 N FLORIDA AVE STE A, TAMPA, FL 33612-6707
(813) 220-1400
(813) 440-6484
Mailing address
PO BOX 17175, TAMPA, FL 33682-7175
(813) 220-1400
(813) 341-4004
Taxonomy
Speciality
Code
Description
License number
State
207QA0505X
Adult Medicine Physician
—
—
2084A0401X
Addiction Medicine (Psychiatry & Neurology) Physician
—
—
2084P0800X
Psychiatry Physician
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
—
—
261QP2300X
Primary Care Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
104624600
—
FL
01
—
LK078
MEDICARE
FL
Enumeration date
02/26/2014
Last updated
10/03/2024
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