Healthcare Provider Details

I. General information

NPI: 1770530024
Provider Name (Legal Business Name): RICHARD RETHORST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 03/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 BAILEY LN
BENTON IL
62812-1969
US

IV. Provider business mailing address

201 BAILEY LN
BENTON IL
62812-1969
US

V. Phone/Fax

Practice location:
  • Phone: 618-439-3161
  • Fax: 618-435-2969
Mailing address:
  • Phone: 618-439-3161
  • Fax: 618-435-2969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036111109
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: