Healthcare Provider Details

I. General information

NPI: 1982959664
Provider Name (Legal Business Name): MARK RAYMOND HIGHTOWER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 S 6TH ST
BRAINERD MN
56401-4529
US

IV. Provider business mailing address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

V. Phone/Fax

Practice location:
  • Phone: 218-828-7101
  • Fax:
Mailing address:
  • Phone: 701-364-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number61942
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: