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General NPI Number Information
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NPI Number | 1770860504
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Entity Type | Organization
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Legal Business Name | SERGE P. POULIN, MD
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Dates
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Enumeration Date | 11/08/2011
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Last Update Date | 11/08/2011
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Provider Practice Location Address
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Address Line | 629 E MIDDLE TPKE
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City | MANCHESTER
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State | CT
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Zip | 06040-3731
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Country | US
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Telephone | 860-649-6900
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Fax | 860-647-0469
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Provider Business Mailing Address
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Address Line | 629 E MIDDLE TPKE
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City | MANCHESTER
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State | CT
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Zip | 06040-3731
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Country | US
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Telephone | 860-649-6900
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Fax | 860-647-0469
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | LOUSIE POULIN
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Credential |
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Telephone | 860-649-6900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 027117
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License Number State | CT
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