MEDICARE: PHILIP CHARLES MARIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0122X	Plastic and Reconstructive Surgery Physician	0040500	CO
2	208200000X	Plastic Surgery Physician	40500	CO
3	2082S0105X	Surgery of the Hand (Plastic Surgery) Physician	40500	CO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00213540	OTHER		MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	61101	OTHER		HUMANA GOLD
2	00073	OTHER		HMO CO
4	TDDIR	OTHER		TRICARE
5	00320	OTHER		INSURANCE
6	MA65799	OTHER	CO	BLUE CROSS BLUE SHIELD
7	71412	OTHER		UNITED OF OMAHA

General Provider Information

NPI Number	:	1205868544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILIP CHARLES MARIN MD

Provider Business Mailing Address
First Line	:	1304 N GRAND AVE
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003-2718
Country	:	US
Telephone Number	:	719-669-8487
Fax Number	:	719-669-8488

Provider Business Practice Location Address
First Line	:	1304 N GRAND AVE
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003-2718
Country	:	US
Telephone Number	:	719-669-8487
Fax Number	:	719-669-8488

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	04/05/2023

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Directions to “ PHILIP CHARLES MARIN MD” Practice Location

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