Main Street Medical Group LLC
General Practice in O Fallon, IL. Organization (NPI-2).
NPI number1043832769
StatusActive
Last updated in NPPESMay 4, 2021
Details
- NPI
- 1043832769
- Entity type
- Organization (NPI-2)
- Legal business name
- Main Street Medical Group LLC
- Organization subpart
- No
- Enumeration date
- May 15, 2020
- Certification date
- May 4, 2021
- Last updated
- May 4, 2021
Medicare and OIG
- Medicare enrolled (PECOS)
- Not in the Medicare enrollment file
- Can order and refer
- Not on the CMS order and referring list
- OIG exclusion list
- This NPI is not listed
CMS and OIG files of November 2026. PECOS lookup · OIG exclusion check
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 208D00000X | General Practice | – | – | Yes |
| 363LF0000X | Nurse Practitioner, Family | – | – | |
| 111N00000X | Chiropractor | – | – | |
| 207R00000X | Internal Medicine | – | – | |
| 225100000X | Physical Therapist | – | – | |
| 363A00000X | Physician Assistant | – | – |
Practice location
124 Regency Park Ste 7O Fallon, IL 62269-1994
Phone 480-926-2260
Mailing address
2250 E Germann Rd Ste 8Chandler, AZ 85286-1575
Phone 480-926-7800
Authorized official
Ellie Descalzo
Credentialing Officer
4809267800
Is something wrong?
This page shows exactly what the provider filed with NPPES. Only the provider (or their surrogate) can change it, by signing in to NPPES. Our page updates within a day of their change. See how to update NPI information.
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