Healthcare Provider Details

I. General information

NPI: 1710902671
Provider Name (Legal Business Name): CORVASC MDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8433 HARCOURT ROAD SUITE 100
INDIANAPOLIS IN
46260-2193
US

IV. Provider business mailing address

8433 HARCOURT ROAD SUITE 300
INDIANAPOLIS IN
46260-2190
US

V. Phone/Fax

Practice location:
  • Phone: 317-583-7600
  • Fax: 317-583-7601
Mailing address:
  • Phone: 317-583-7702
  • Fax: 317-583-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number50000804A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number50000804A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number50000804A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number50000804A
License Number StateIN

VIII. Authorized Official

Name: MS. LYNNE TROMBLE
Title or Position: ADMINISTRATOR
Credential:
Phone: 317-583-7600