Provider Demographics
NPI:1316027204
Name:MARK, SAMUEL B (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:B
Last Name:MARK
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 1:218 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4306
Mailing Address - Country:US
Mailing Address - Phone:308-633-2200
Mailing Address - Fax:
Practice Address - Street 1:218 W 27TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4306
Practice Address - Country:US
Practice Address - Phone:308-633-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
NE1333111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE99671OtherBLUE CROSS BLUE SHIELD
NE99671OtherBLUE CROSS BLUE SHIELD
NEU97319Medicare UPIN