Provider Demographics
NPI:1629112958
Name:RAUTENBERG, MARK ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:RAUTENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MERRILL BROOK DR
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9194
Mailing Address - Country:US
Mailing Address - Phone:207-883-4145
Mailing Address - Fax:207-490-7452
Practice Address - Street 1:17 MERRILL BROOK DR
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9194
Practice Address - Country:US
Practice Address - Phone:207-883-4145
Practice Address - Fax:207-490-7452
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME12338207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEB86429Medicare UPIN
MEMM0924-RAMedicare ID - Type Unspecified