NPIMap

Organization Active NPI

Main Street Medical Center Inc

  • Internal Medicine Physician
  • Shenandoah, PA
National Provider Identifier
1063561041
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Internal Medicine PhysicianTaxonomy code 207R00000X
License
MD418365 Issued in PA
Legal business name
MAIN STREET MEDICAL CENTER INC
Practice address
24 South Main Street
Shenandoah, PA 17976
Phone
(570) 462-1033
Fax
(570) 462-1171
NPI assigned
Jan 9, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

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

Authorized official

Name
Mr. Adolph Michael Wychulis, MDNPI 1023001617
Title
Owner
Phone
(570) 462-1033

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X MD418365 PA Primary

Addresses

Primary practice location

24 South Main Street
Shenandoah, PA 17976

Mailing address

24 South Main Street
Shenandoah, PA 17976
Phone (570) 462-1033

Other identifiers 1

IdentifierTypeStateIssuer
0019487500001MedicaidPA

National Provider Directory

National Provider Directory

Locations

24 S Main St
Shenandoah, PA 17976
Phone (570) 462-1033

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1168300800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1063561041",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "24 SOUTH MAIN STREET",
            "city": "SHENANDOAH",
            "state": "PA",
            "postal_code": "17976",
            "telephone_number": "570-462-1033",
            "fax_number": "570-462-1171"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "24 SOUTH MAIN STREET",
            "city": "SHENANDOAH",
            "state": "PA",
            "postal_code": "17976",
            "telephone_number": "570-462-1033",
            "fax_number": "570-462-1171"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAIN STREET MEDICAL CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-09",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "WYCHULIS",
        "authorized_official_first_name": "ADOLPH",
        "authorized_official_middle_name": "MICHAEL",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "570-462-1033",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": "PA",
            "license": "MD418365",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0019487500001",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Shenandoah, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; 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.