Healthcare Provider Details

I. General information

NPI: 1083124010
Provider Name (Legal Business Name): SERGE B PIERRECHARLES MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2017
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9220 BASS LAKE RD SUITE 350
NEW HOPE MN
55428-3095
US

IV. Provider business mailing address

9220 BASS LAKE RD SUITE 350
NEW HOPE MN
55428-3095
US

V. Phone/Fax

Practice location:
  • Phone: 763-208-9545
  • Fax: 651-927-8668
Mailing address:
  • Phone: 763-208-9545
  • Fax: 651-927-8668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number58656
License Number StateMN

VIII. Authorized Official

Name: DR. SERGE B PIERRECHARLES
Title or Position: OWNER
Credential: MD
Phone: 646-234-3795