Provider Demographics
NPI:1376588434
Name:RETTERATH, PATRICK L (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:L
Last Name:RETTERATH
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 1:1201 MICKELSON DR STE 2
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-7253
Mailing Address - Country:US
Mailing Address - Phone:605-882-0432
Mailing Address - Fax:605-882-0978
Practice Address - Street 1:1512 4TH ST NE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-6824
Practice Address - Country:US
Practice Address - Phone:605-884-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD2779207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4995672OtherBCBS
SD5700375Medicaid
SD5700374Medicaid
MN014226300Medicaid
SDP00188650Medicare ID - Type UnspecifiedRAILROAD
E32871Medicare UPIN
SD5700374Medicaid
SD5700375Medicaid