Provider Demographics
NPI:1174712814
Name:SERGE P. POULIN, MD
Entity type:Organization
Organization Name:SERGE P. POULIN, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOUISE
Authorized Official - Middle Name:
Authorized Official - Last Name:POULIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-649-6900
Mailing Address - Street 1:315 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-5251
Mailing Address - Country:US
Mailing Address - Phone:860-649-6900
Mailing Address - Fax:860-647-0469
Practice Address - Street 1:315 E CENTER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-5251
Practice Address - Country:US
Practice Address - Phone:860-649-6900
Practice Address - Fax:860-647-0469
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SERGE P. POULIN, MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT027117OtherCONNECTICARE
CT0102711703OtherCIGNA
CT010027117CT01OtherBC
CT0104460OtherUNITED
CT0V0122OtherHEALTHNET
CTB37894Medicare UPIN