Healthcare Provider Details

I. General information

NPI: 1609863729
Provider Name (Legal Business Name): MARK R HILTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 HIGHLAND AVE
FALL RIVER MA
02720-3703
US

IV. Provider business mailing address

200 MILL RD STE 180
FAIRHAVEN MA
02719-5252
US

V. Phone/Fax

Practice location:
  • Phone: 508-973-7447
  • Fax: 508-973-7424
Mailing address:
  • Phone: 508-973-2000
  • Fax: 508-973-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number81533
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierMH13050
Identifier TypeMEDICAID
Identifier StateRI
Identifier Issuer
# 2
Identifier110056214A
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: