Healthcare Provider Details

I. General information

NPI: 1114998440
Provider Name (Legal Business Name): COLIN R RAITIERE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 ENTERPRISE DR
DANVILLE KY
40422-1870
US

IV. Provider business mailing address

120 ENTERPRISE DR
DANVILLE KY
40422-1870
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-2425
  • Fax: 859-757-2475
Mailing address:
  • Phone: 859-236-2425
  • Fax: 859-757-2475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19619
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number19619
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: