Main Street Family Medical, LLC

Primary specialty

Primary Care Clinic/CenterTaxonomy code 261QP2300X

Legal business name

MAIN STREET FAMILY MEDICAL, LLC

Practice address

701 W Broadway St
Spiro, OK 74959-2456

Phone

(918) 962-8009

Fax

(918) 962-8027

NPI assigned

Sep 29, 2022

Organization subpart

No

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

Authorized official

Name

Elizabeth Trudy Davis, APRN-CNPNPI 1033837000

Title

Founder

Phone

(918) 448-7854

Specialties & licenses 1

Addresses

Electronic endpoints 2

Medicare fee-for-service enrollment

Enrolled in OK

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 1

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

• Elizabeth Trudy Davis, APRN-CNP

  • Family Nurse Practitioner
  • Spiro, OK
  • NPI 1033837000
  Medicare reassignment NPD Authorized official

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

{
    "created_epoch": "1664409600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1694044800000",
    "number": "1952025249",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "32415 PEACH CREEK RD",
            "city": "RED OAK",
            "state": "OK",
            "postal_code": "745631101",
            "telephone_number": "918-448-7854"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "701 W BROADWAY ST",
            "city": "SPIRO",
            "state": "OK",
            "postal_code": "749592456",
            "telephone_number": "918-962-8009",
            "fax_number": "918-962-8027"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAIN STREET FAMILY MEDICAL, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-09-29",
        "last_updated": "2023-09-07",
        "certification_date": "2023-09-07",
        "status": "A",
        "authorized_official_last_name": "DAVIS",
        "authorized_official_first_name": "ELIZABETH",
        "authorized_official_middle_name": "TRUDY",
        "authorized_official_title_or_position": "FOUNDER",
        "authorized_official_telephone_number": "918-448-7854",
        "authorized_official_credential": "APRN-CNP"
    },
    "taxonomies": [
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "Kareo",
            "affiliation": "N",
            "endpointDescription": "EHR",
            "address_1": "221 S Main St",
            "city": "Spiro",
            "state": "OK",
            "country_code": "US",
            "postal_code": "749592505",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "Kareo",
            "affiliation": "N",
            "endpointDescription": "EHR",
            "address_1": "701 W Broadway St",
            "city": "Spiro",
            "state": "OK",
            "country_code": "US",
            "postal_code": "749592456",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Imaginus Diagnostic Laboratory LLC
• Angela Johnson, MS, CCC-SLP
• Sadaea' Jones, BSN, RN
• Darla Dyanne King
• Grace Lovelace, COMS, CTVI
• Marcella P Jones DO PLLC
• Osu Center for Health Sciences (Osu-Aj Baptist Health Spiro)
• Lameisha Marquita Phillips, PRSS, CM1,
• Jada Marie Ray
• Taylor Ridenour, DDS

• Primary Care Clinic/Center in Spiro, OK
• Providers in Spiro, OK by specialty
• Primary Care Clinic/Center in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.