Healthcare Provider Details

I. General information

NPI: 1134380843
Provider Name (Legal Business Name): NICHOLAS D RATHERT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 05/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HEALTH CARE DR
GREENVILLE IL
62246-1154
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8072
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 618-664-1230
  • Fax:
Mailing address:
  • Phone: 314-362-9123
  • Fax: 314-747-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2012009157
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036147452
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: