Provider Demographics
NPI:1710902671
Name:CORVASC MDS PC
Entity Type:Organization
Organization Name:CORVASC MDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNNE
Authorized Official - Middle Name:
Authorized Official - Last Name:TROMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-583-7600
Mailing Address - Street 1:8433 HARCOURT ROAD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2190
Mailing Address - Country:US
Mailing Address - Phone:317-583-7702
Mailing Address - Fax:317-583-7601
Practice Address - Street 1:8433 HARCOURT ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2193
Practice Address - Country:US
Practice Address - Phone:317-583-7600
Practice Address - Fax:317-583-7601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000804A204F00000X, 2085R0204X, 2086S0129X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No204F00000XAllopathic & Osteopathic PhysiciansTransplant SurgeryGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100056810Medicaid
CA1027OtherRAILROAD MEDICARE
CN0273OtherRAILROAD MEDICARE
CN0337OtherRAILROAD MEDICARE
CN0337OtherRAILROAD MEDICARE