Provider Demographics
NPI:1033207303
Name:SEGERSTROM, MARK C (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:C
Last Name:SEGERSTROM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-1903
Mailing Address - Country:US
Mailing Address - Phone:207-879-5433
Mailing Address - Fax:207-879-5433
Practice Address - Street 1:2001 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1903
Practice Address - Country:US
Practice Address - Phone:207-879-5433
Practice Address - Fax:207-879-5433
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME0989216111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME017234OtherANTHEM BCBSME ID
ME1041785OtherAETNA HEALTHCARE PIN
MEMM3983Medicare PIN
MEU25469Medicare UPIN