Provider Demographics
NPI:1083124010
Name:SERGE B PIERRECHARLES MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:SERGE B PIERRECHARLES MEDICAL GROUP PLLC
Other - Org Name:SUPERIOR PERFORMANCE CENTER SPORTS MEDICINE, PAIN, SPINE, REHABILITAT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGE
Authorized Official - Middle Name:B
Authorized Official - Last Name:PIERRECHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-234-3795
Mailing Address - Street 1:9220 BASS LAKE RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-3095
Mailing Address - Country:US
Mailing Address - Phone:763-208-9545
Mailing Address - Fax:651-927-8668
Practice Address - Street 1:9220 BASS LAKE RD
Practice Address - Street 2:SUITE 350
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55428-3095
Practice Address - Country:US
Practice Address - Phone:763-208-9545
Practice Address - Fax:651-927-8668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-04
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58656261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center