Provider Demographics
NPI:1215954938
Name:POULIN, SERGE PETER (MD)
Entity type:Individual
Prefix:MR
First Name:SERGE
Middle Name:PETER
Last Name:POULIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
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
Practice Address - Country:US
Practice Address - Phone:860-649-6900
Practice Address - Fax:860-647-0469
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT027117207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT027117Medicaid
CT001271171Medicaid
B37894Medicare UPIN
080000613Medicare PIN
CT001271171Medicaid