Provider Demographics
NPI:1356492219
Name:CORWIN CLINIC SURGICAL PROFESSIONAL CORP
Entity Type:Organization
Organization Name:CORWIN CLINIC SURGICAL PROFESSIONAL CORP
Other - Org Name:CORWIN CLINIC SURGICAL, PC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-564-0210
Mailing Address - Street 1:1925 E ORMAN AVE STE A109
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3555
Mailing Address - Country:US
Mailing Address - Phone:719-564-0210
Mailing Address - Fax:719-564-9483
Practice Address - Street 1:1925 E ORMAN AVE STE A109
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3555
Practice Address - Country:US
Practice Address - Phone:719-564-0210
Practice Address - Fax:719-564-9483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04011417Medicaid
CO04011417Medicaid
CO=========OtherGROUP TAX ID NUMBER