| Entity Name: | MAIN STREET MEDICAL LLC |
| Jurisdiction: | FLORIDA |
| Filing Type: | Florida Limited Liability Co. |
| Status: | Active |
| Date Filed: | 04 May 2017 (8 years ago) |
| Last Event: | REINSTATEMENT |
| Event Date Filed: | 11 Oct 2021 (3 years ago) |
| Document Number: | L17000099285 |
| FEI/EIN Number | 824801307 |
| Mail Address: | P.O. BOX 17175, TAMPA, FL, 33682, US |
| Address: | 10549 N FLORIDA AVENUE, TAMPA, FL, 33612, US |
| ZIP code: | 33612 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1487079505 | 2014-02-26 | 2024-10-03 | PO BOX 17175, TAMPA, FL, 336827175, US | 10549 N FLORIDA AVE STE A, TAMPA, FL, 336126707, US | |||||||||||||||||||||||||||||||||||||||||||||
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| Phone | +1 813-220-1400 |
| Fax | 8133414004 |
| Fax | 8134406484 |
Authorized person
| Name | MR. STEPHEN O BANJOKO |
| Role | CFO |
| Phone | 2122570225 |
Taxonomy
| Taxonomy Code | 207QA0505X - Adult Medicine Physician |
| Is Primary | No |
| Taxonomy Code | 2084A0401X - Addiction Medicine (Psychiatry & Neurology) Physician |
| Is Primary | No |
| Taxonomy Code | 2084P0800X - Psychiatry Physician |
| Is Primary | No |
| Taxonomy Code | 261QM0801X - Mental Health Clinic/Center (Including Community Mental Health Center) |
| Is Primary | No |
| Taxonomy Code | 261QP2300X - Primary Care Clinic/Center |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 104624600 |
| State | FL |
| Issuer | MEDICARE |
| Number | LK078 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| BANJOKO CASEY | Agent | 10549 N FLORIDA AVENUE, TAMPA, FL, 33612 |
| Name | Role | Address |
|---|---|---|
| BANJOKO STEPHEN O | Chief Financial Officer | P. O. BOX 17175, Tampa, FL, 33682 |
| Name | Role | Address |
|---|---|---|
| BANJOKO CASEY | Chief Operating Officer | P. O. BOX 17175, TAMPA, FL, 33682 |
| Registration Number | Fictitious Name | Status | Filed Date | Expiration Date | Cancellation Date | Mailing Address |
|---|---|---|---|---|---|---|
| G20000037508 | MAIN STREET MEDICAL CENTERS | ACTIVE | 2020-04-02 | 2025-12-31 | No data | P. O. BOX 17175, TAMPA, FL, 33682 |
| G20000037332 | MAIN STRET MEDICAL CENTERS | ACTIVE | 2020-04-01 | 2025-12-31 | No data | P. O. BOX 17175, TAMPA, FL, 33682 |
| G18000059652 | MAIN STREET URGENT CARE | EXPIRED | 2018-05-16 | 2023-12-31 | No data | P. O. BOX 17175, TAMPA, FL, 33682 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-04-30 | 10549 N FLORIDA AVENUE, SUITE A, TAMPA, FL 33612 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-04-30 | 10549 N FLORIDA AVENUE, SUITE A, TAMPA, FL 33612 | No data |
| REINSTATEMENT | 2021-10-11 | No data | No data |
| REGISTERED AGENT NAME CHANGED | 2021-10-11 | BANJOKO, CASEY | No data |
| ADMIN DISSOLUTION FOR ANNUAL REPORT | 2021-09-24 | No data | No data |
| CHANGE OF MAILING ADDRESS | 2018-04-11 | 10549 N FLORIDA AVENUE, SUITE A, TAMPA, FL 33612 | No data |
| LC AMENDMENT AND NAME CHANGE | 2018-03-08 | MAIN STREET MEDICAL LLC | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-30 |
| ANNUAL REPORT | 2023-04-04 |
| ANNUAL REPORT | 2022-04-30 |
| REINSTATEMENT | 2021-10-11 |
| ANNUAL REPORT | 2020-03-12 |
| ANNUAL REPORT | 2019-02-06 |
| ANNUAL REPORT | 2018-04-11 |
| LC Amendment and Name Change | 2018-03-08 |
| Florida Limited Liability | 2017-05-04 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
