NPIMap

Organization Active NPI

Corwin Clinic Surgical Professional Corp

  • Specialist
  • Pueblo, CO
National Provider Identifier
1356492219
Registry record updated Mar 23, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
SpecialistTaxonomy code 174400000X
Legal business name
CORWIN CLINIC SURGICAL PROFESSIONAL CORP
Practice address
1925 E Orman Ave Ste A109
Pueblo, CO 81004-3555
Phone
(719) 564-0210
Fax
(719) 564-9483
NPI assigned
Jan 16, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 23, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Gary E. Lane, MDNPI 1841282498
Title
President
Phone
(719) 564-0210

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
SpecialistGroup: 193400000X SINGLE SPECIALTY GROUP 174400000X Primary

Addresses

Primary practice location

1925 E Orman Ave Ste A109
Pueblo, CO 81004-3555

Mailing address

1925 E Orman Ave Ste A109
Pueblo, CO 81004-3555
Phone (719) 564-0210

Other identifiers 1

IdentifierTypeStateIssuer
04011417MedicaidCO

Other names 1

  • Corwin Clinic Surgical, PC Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040413000226 CO Part B Supplier - Clinic/Group Practice 4981698958 Receives reassigned benefits from 2 practitioners
Practice locations: Pueblo, CO

National Provider Directory

National Provider Directory

Locations

1925 E Orman Ave
Ste A109
Pueblo, CO 81004
Phone (719) 562-0210

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1168905600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1300838400000",
    "number": "1356492219",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1925 E ORMAN AVE STE A109",
            "city": "PUEBLO",
            "state": "CO",
            "postal_code": "810043555",
            "telephone_number": "719-564-0210",
            "fax_number": "719-564-9483"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1925 E ORMAN AVE STE A109",
            "city": "PUEBLO",
            "state": "CO",
            "postal_code": "810043555",
            "telephone_number": "719-564-0210",
            "fax_number": "719-564-9483"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CORWIN CLINIC SURGICAL PROFESSIONAL CORP",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-16",
        "last_updated": "2011-03-23",
        "status": "A",
        "authorized_official_last_name": "LANE",
        "authorized_official_first_name": "GARY",
        "authorized_official_middle_name": "E.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "719-564-0210",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Specialist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "04011417",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Corwin Clinic Surgical, PC",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Pueblo, CO

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 23, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.