Provider Demographics
NPI:1134125834
Name:BAIN, LAURIE ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:ANN
Last Name:BAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 HARTFORD TPKE
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4838
Mailing Address - Country:US
Mailing Address - Phone:860-871-9441
Mailing Address - Fax:860-871-0227
Practice Address - Street 1:357 HARTFORD TPKE
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4838
Practice Address - Country:US
Practice Address - Phone:860-871-9441
Practice Address - Fax:860-871-0227
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028806207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B37999Medicare UPIN