Provider Demographics
NPI:1154540235
Name:INNOVATIVE SURGERY AND MEDICINE, PC
Entity type:Organization
Organization Name:INNOVATIVE SURGERY AND MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RINA
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHINN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-546-4947
Mailing Address - Street 1:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81002-0566
Mailing Address - Country:US
Mailing Address - Phone:719-286-5840
Mailing Address - Fax:719-542-0746
Practice Address - Street 1:1600 W 24TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-1411
Practice Address - Country:US
Practice Address - Phone:719-546-4947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2008-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI659839OtherBCBS
DA7417OtherRR MEDICARE
CO01358845Medicaid
COG45359Medicare UPIN
CO01358845Medicaid