Provider Demographics
NPI:1205815180
Name:SERINE, ENRICO A (MD)
Entity Type:Individual
Prefix:
First Name:ENRICO
Middle Name:A
Last Name:SERINE
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 1:1140 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18510-1150
Mailing Address - Country:US
Mailing Address - Phone:570-983-0369
Mailing Address - Fax:570-983-0375
Practice Address - Street 1:1140 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18510-1150
Practice Address - Country:US
Practice Address - Phone:570-983-0369
Practice Address - Fax:570-983-0375
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025938E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00823724Medicaid
PA416208Medicare PIN
B41436Medicare UPIN