Provider Demographics
NPI:1255334439
Name:RETTIG, RICHARD (DPM)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:RETTIG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 RIDGERUN LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-1357
Mailing Address - Country:US
Mailing Address - Phone:215-285-1013
Mailing Address - Fax:
Practice Address - Street 1:1335 W TABOR RD
Practice Address - Street 2:STE 206
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3040
Practice Address - Country:US
Practice Address - Phone:215-927-2837
Practice Address - Fax:215-927-2008
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-002203-L213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA480001607OtherRAILROAD MEDICARE
PA0007644720004Medicaid
PA23-2215135OtherFEDERAL ITIN
PARE154276Medicare PIN
PAT29712Medicare UPIN
PA0367690001Medicare NSC