Healthcare Provider Details

I. General information

NPI: 1548250020
Provider Name (Legal Business Name): MATTHEW SCOTT RETTKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 12/29/2020
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E MICHIGAN AVE
GRAYLING MI
49738-7074
US

IV. Provider business mailing address

3781 MOMENTUM PLACE
CHICAGO IL
60689-5337
US

V. Phone/Fax

Practice location:
  • Phone: 989-348-0550
  • Fax: 989-348-0473
Mailing address:
  • Phone: 231-935-6080
  • Fax: 231-935-6081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301064367
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: