Main Street Medical Group LLC

NPI #1043832769 in O Fallon, Illinois

Provider Information

NPI Number: 1043832769
Entity Type: Organization
Organization Name: Main Street Medical Group LLC
Primary Specialty: General Practice
Enumeration Date: May 15, 2020
Last Updated: May 4, 2021

Practice Location

Address: 124 REGENCY PARK STE 7
City: O Fallon
State: Illinois
ZIP Code: 62269-1994
Phone: (480) 926-2260

Authorized Official

Name: ELLIE DESCALZO
Title: CREDENTIALING OFFICER
Phone: (480) 926-7800

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Nurse Practitioner - Family — Family	363LF0000X
Chiropractor	111N00000X
Internal Medicine	207R00000X
Physical Therapist	225100000X
Physician Assistant	363A00000X
General Practice	208D00000X	Primary

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