Provider Demographics
NPI:1861431587
Name:RETTIG, KENNETH R (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:RETTIG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40480
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0480
Mailing Address - Country:US
Mailing Address - Phone:251-410-5437
Mailing Address - Fax:251-434-3852
Practice Address - Street 1:1601 CENTER STREET
Practice Address - Street 2:STE 1S
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-3207
Practice Address - Country:US
Practice Address - Phone:251-410-5437
Practice Address - Fax:251-434-3852
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL92102080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255656100Medicaid
AL33-10016OtherUNITED HEALTH CARE
LA1722634Medicaid
AL000015487Medicaid
MS00015345Medicaid
AL51015487OtherBLUE CROSS
FL255656100Medicaid
MS00015345Medicaid