Healthcare Provider Details

I. General information

NPI: 1588634000
Provider Name (Legal Business Name): KIM JOSEPH RETTENMAIER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 E MONROE ST
MEXICO MO
65265-2919
US

IV. Provider business mailing address

705 HOLLY GLEN CT
COLUMBIA MO
65203-3130
US

V. Phone/Fax

Practice location:
  • Phone: 573-582-5000
  • Fax: 573-582-3712
Mailing address:
  • Phone: 573-441-1619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberR7H11
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: