Provider Demographics
NPI:1275502684
Name:RAINE, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RAINE
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:PO BOX 6484
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-1484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3100 S TONGASS HWY
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-9600
Practice Address - Country:US
Practice Address - Phone:907-228-7601
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3402207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKD08004Medicare UPIN