Healthcare Provider Details

I. General information

NPI: 1932150638
Provider Name (Legal Business Name): RICHARD H. ROETTGER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12266 DE PAUL DR STE 305
BRIDGETON MO
63044
US

IV. Provider business mailing address

PO BOX 955534
SAINT LOUIS MO
63195-5534
US

V. Phone/Fax

Practice location:
  • Phone: 314-770-0991
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2014006605
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number23291
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number2014006605
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: