MEDICARE: MARK EDWARD DEWITT STS, NET STUDY2.0

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver

General Provider Information

NPI Number	:	1790643641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK EDWARD DEWITT STS, NET STUDY2.0

Provider Business Mailing Address
First Line	:	1420 ROLAND RD
Second Line	:
City	:	CLOQUET
State	:	MN
Zip	:	55720-2919
Country	:	US
Telephone Number	:	218-800-7066
Fax Number	:

Provider Business Practice Location Address
First Line	:	1420 ROLAND RD
Second Line	:
City	:	CLOQUET
State	:	MN
Zip	:	55720-2919
Country	:	US
Telephone Number	:	218-800-7066
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2026
Last Update Date	:	01/12/2026

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