Healthcare Provider Details

I. General information

NPI: 1497934558
Provider Name (Legal Business Name): PHILIP C. MARIN, MD PROF LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 DITTMER AVE
PUEBLO CO
81005-1212
US

IV. Provider business mailing address

650 DITTMER AVE
PUEBLO CO
81005-1212
US

V. Phone/Fax

Practice location:
  • Phone: 719-565-1000
  • Fax: 719-565-1111
Mailing address:
  • Phone: 719-565-1000
  • Fax: 719-565-1111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number40500
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number40500
License Number StateCO

VIII. Authorized Official

Name: PHILIP C. MARIN
Title or Position: OWNER
Credential: MD
Phone: 719-565-1000