Provider Demographics
NPI:1497934558
Name:PHILIP C. MARIN, MD PROF LLC
Entity Type:Organization
Organization Name:PHILIP C. MARIN, MD PROF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-565-1000
Mailing Address - Street 1:650 DITTMER AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1212
Mailing Address - Country:US
Mailing Address - Phone:719-565-1000
Mailing Address - Fax:719-565-1111
Practice Address - Street 1:650 DITTMER AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-1212
Practice Address - Country:US
Practice Address - Phone:719-565-1000
Practice Address - Fax:719-565-1111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40500208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO801605Medicare PIN