1922006964 NPI number — DR. MARC E HAGEBUSCH D.C.

Table of content: DR. MARC E HAGEBUSCH D.C. (NPI 1922006964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922006964 NPI number — DR. MARC E HAGEBUSCH D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAGEBUSCH
Provider First Name:
MARC
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1922006964
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3506 PINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEXARKANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75503-3666
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-244-3496
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3801 N STATE LINE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEXARKANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75503-3132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-792-3763
Provider Business Practice Location Address Fax Number:
903-792-6898
Provider Enumeration Date:
07/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111NX0800X , with the licence number:  7000 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PO89Y5638 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 91929 . This is a "BLUE CROSS GROUP" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 89Y563 . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 98206 . This is a "BLUE CROSS INDIVIDUAL" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: 91929 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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