Healthcare Provider Details

I. General information

NPI: 1134125834
Provider Name (Legal Business Name): LAURIE ANN BAIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 HARTFORD TPKE
VERNON CT
06066-4838
US

IV. Provider business mailing address

357 HARTFORD TPKE
VERNON CT
06066-4838
US

V. Phone/Fax

Practice location:
  • Phone: 860-871-9441
  • Fax: 860-871-0227
Mailing address:
  • Phone: 860-871-9441
  • Fax: 860-871-0227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number028806
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: