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 1:1355 GETZ RD STE C
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1609
Mailing Address - Country:US
Mailing Address - Phone:260-413-5879
Mailing Address - Fax:
Practice Address - Street 1:1355 GETZ RD STE C
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1609
Practice Address - Country:US
Practice Address - Phone:260-413-5879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2025-10-27
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