Provider Demographics
NPI:1528097433
Name:MAIN STREET FAMILY MEDICINE, LLC
Entity type:Organization
Organization Name:MAIN STREET FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:DIANNE
Authorized Official - Last Name:GLENN-BIRKHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:270-233-1884
Mailing Address - Street 1:10015 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42378-9557
Mailing Address - Country:US
Mailing Address - Phone:270-233-1884
Mailing Address - Fax:270-233-9520
Practice Address - Street 1:10015 MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITESVILLE
Practice Address - State:KY
Practice Address - Zip Code:42378-9557
Practice Address - Country:US
Practice Address - Phone:270-233-1884
Practice Address - Fax:270-233-9520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363LF0000X
KY2848P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPASSPORTOther50010742
KYBLUE CROSS BLUE SHIEOther000000480521
KYG72337Medicare UPIN