Basic Information
| Provider Information | |||||||||
| NPI: | 1861431587 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RETTIG | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40480 | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366400480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514105437 | ||||||||
| FaxNumber: | 2514343852 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 CENTER STREET | ||||||||
| Address2: | STE 1S | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366043207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2514105437 | ||||||||
| FaxNumber: | 2514343852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 03/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0205X | 9210 | AL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 255656100 | 05 | FL | MEDICAID | 33-10016 | 01 | AL | UNITED HEALTH CARE | OTHER | 1722634 | 05 | LA | MEDICAID | 000015487 | 05 | AL | MEDICAID | 00015345 | 05 | MS | MEDICAID | 51015487 | 01 | AL | BLUE CROSS | OTHER |