Provider Demographics
NPI:1922006964
Name:HAGEBUSCH, MARC E (DC)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:E
Last Name:HAGEBUSCH
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 1:3506 PINE ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3666
Mailing Address - Country:US
Mailing Address - Phone:903-244-3496
Mailing Address - Fax:
Practice Address - Street 1:3801 N STATE LINE AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3132
Practice Address - Country:US
Practice Address - Phone:903-792-3763
Practice Address - Fax:903-792-6898
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7000111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPO89Y5638Medicaid
AR91929OtherBLUE CROSS GROUP
TX89Y563OtherBLUE CROSS
AR98206OtherBLUE CROSS INDIVIDUAL
AR91929Medicaid
AR91929OtherBLUE CROSS GROUP
TX89Y563Medicare ID - Type Unspecified
TXPO89Y5638Medicaid