Provider Demographics
NPI:1871593418
Name:RETTENMAIER, PHILIP A (DO)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:A
Last Name:RETTENMAIER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3514
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:7900 W JEFFERSON BLVD STE 202
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-435-4730
Practice Address - Fax:260-435-4731
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001284A2083P0011X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200073610Medicaid
IN200073610Medicaid
ININ1205003Medicare PIN
INB66700Medicare UPIN
IN200073610Medicaid