Provider Demographics
NPI:1932150638
Name:ROETTGER, RICHARD H (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:H
Last Name:ROETTGER
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:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12266 DE PAUL DR STE 305
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:314-770-0991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014006605208600000X, 2086S0127X
SC23291208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01002Medicaid
SC020052517OtherRR MEDICARE
SC4279822OtherAETNA ID
SC576007863077OtherBCBS OF SC ID
SC3087952OtherCIGNA ID
SCD94029Medicare UPIN
SCD940297951Medicare PIN
SCD940293640Medicare PIN