Provider Demographics
NPI:1114998440
Name:RAITIERE, COLIN R (MD)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:R
Last Name:RAITIERE
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 1:120 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-1870
Mailing Address - Country:US
Mailing Address - Phone:859-236-2425
Mailing Address - Fax:859-757-2475
Practice Address - Street 1:120 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1870
Practice Address - Country:US
Practice Address - Phone:859-236-2425
Practice Address - Fax:859-757-2475
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19619207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0000000323180OtherANTHEM BC/BS
P00156824OtherRAILROAD MEDICARE
KY64196199Medicaid
KY0000000323180OtherANTHEM BC/BS
0599403Medicare ID - Type Unspecified