Main Street Medical Group LLC

Primary specialty

General Practice PhysicianTaxonomy code 208D00000X

Legal business name

MAIN STREET MEDICAL GROUP LLC

Practice address

124 Regency Park Ste 7
O Fallon, IL 62269-1994

Phone

(480) 926-2260

NPI assigned

May 15, 2020

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Ellie Descalzo

Title

Credentialing Officer

Phone

(480) 926-7800

Specialties & licenses 6

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1589500800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1620086400000",
    "number": "1043832769",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2250 E GERMANN RD STE 8",
            "city": "CHANDLER",
            "state": "AZ",
            "postal_code": "852861575",
            "telephone_number": "480-926-7800"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "124 REGENCY PARK STE 7",
            "city": "O FALLON",
            "state": "IL",
            "postal_code": "622691994",
            "telephone_number": "480-926-2260"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAIN STREET MEDICAL GROUP LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-05-15",
        "last_updated": "2021-05-04",
        "certification_date": "2021-05-04",
        "status": "A",
        "authorized_official_last_name": "DESCALZO",
        "authorized_official_first_name": "ELLIE",
        "authorized_official_title_or_position": "CREDENTIALING OFFICER",
        "authorized_official_telephone_number": "480-926-7800"
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Chiropractor",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "225100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Kayla Lynn
• Bassam N Maalouf, M.D.
• Abigail Elizabeth Mackin
• Zachary J Madej, PHARMD
• Danielle Maggio
• Carol A Makarewicz, RPH
• Gabriele E Malone, RBT
• Angela Nicole Mangum
• Angela Mann, RNC-OB, IBCLC
• Sarah R Mannix

• General Practice Physician in O Fallon, IL
• Providers in O Fallon, IL by specialty
• General Practice Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 4, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.