Provider Demographics
NPI:1699884379
Name:CORMIER, SERGE (MD)
Entity type:Individual
Prefix:
First Name:SERGE
Middle Name:
Last Name:CORMIER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:SERGE
Other - Middle Name:
Other - Last Name:CORMIER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:66 HOSPITAL PLAZA
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WESTON
Mailing Address - State:WV
Mailing Address - Zip Code:26452
Mailing Address - Country:US
Mailing Address - Phone:304-269-3108
Mailing Address - Fax:304-269-3109
Practice Address - Street 1:12 HARTMAN PLAZA
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201
Practice Address - Country:US
Practice Address - Phone:304-473-0670
Practice Address - Fax:304-472-5255
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16774207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0092089000Medicaid
WA000708293OtherMOUNTAIN STATE BCBS
WA000708293OtherMOUNTAIN STATE BCBS
0707173Medicare ID - Type Unspecified
WV0092089000Medicaid