Healthcare Provider Details

I. General information

NPI: 1598925612
Provider Name (Legal Business Name): KERIAN SERVICE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 12/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N MAIN ST
MANCHESTER CT
06042-2003
US

IV. Provider business mailing address

94 CONNECTICUT BLVD
EAST HARTFORD CT
06108-3013
US

V. Phone/Fax

Practice location:
  • Phone: 860-528-1359
  • Fax: 860-290-4142
Mailing address:
  • Phone: 860-528-1359
  • Fax: 860-290-4142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number049742
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: