Provider Demographics
NPI:1700357019
Name:PATRICK D RETTERBUSH MD LLC
Entity Type:Organization
Organization Name:PATRICK D RETTERBUSH MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:RETTERBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-255-3702
Mailing Address - Street 1:1500 OGLETHORPE AVE STE 300A
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2181
Mailing Address - Country:US
Mailing Address - Phone:706-614-1750
Mailing Address - Fax:
Practice Address - Street 1:1500 OGLETHORPE AVE STE 300A
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2181
Practice Address - Country:US
Practice Address - Phone:706-614-1750
Practice Address - Fax:706-480-4185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-13
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty