Provider Demographics
NPI:1598925612
Name:SERVICE, KERIAN (MD)
Entity Type:Individual
Prefix:MRS
First Name:KERIAN
Middle Name:
Last Name:SERVICE
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 1:94 CONNECTICUT BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3013
Mailing Address - Country:US
Mailing Address - Phone:860-528-1359
Mailing Address - Fax:860-290-4142
Practice Address - Street 1:150 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2003
Practice Address - Country:US
Practice Address - Phone:860-528-1359
Practice Address - Fax:860-290-4142
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT049742207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT007228810Medicaid