1083124010 NPI number — SERGE B PIERRECHARLES MEDICAL GROUP PLLC

Table of content: (NPI 1083124010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083124010 NPI number — SERGE B PIERRECHARLES MEDICAL GROUP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERGE B PIERRECHARLES MEDICAL GROUP PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083124010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9220 BASS LAKE RD
Provider Second Line Business Mailing Address:
SUITE 350
Provider Business Mailing Address City Name:
NEW HOPE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55428-3095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-208-9545
Provider Business Mailing Address Fax Number:
651-927-8668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9220 BASS LAKE RD
Provider Second Line Business Practice Location Address:
SUITE 350
Provider Business Practice Location Address City Name:
NEW HOPE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55428-3095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-208-9545
Provider Business Practice Location Address Fax Number:
651-927-8668
Provider Enumeration Date:
10/04/2017

Additional Information

Authorized Official

Authorized Official Last Name:
PIERRECHARLES
Authorized Official First Name:
SERGE
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
646-234-3795

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  58656 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com