1609831189 NPI number — TRESA V RATTERMAN M.D.

Table of content: TRESA V RATTERMAN M.D. (NPI 1609831189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609831189 NPI number — TRESA V RATTERMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RATTERMAN
Provider First Name:
TRESA
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609831189
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776879
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6879
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-9490
Provider Business Mailing Address Fax Number:
502-272-5116

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2051 CLEVIDENCE BLVD STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47129-2278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-280-6623
Provider Business Practice Location Address Fax Number:
812-666-7688
Provider Enumeration Date:
04/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  25265 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 01038674A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1194546 . This is a "CHA / NCMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 2528638-002 . This is a "CIGNA / NCMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 100344080 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64252653 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00000065707 . This is a "ANTHEM / NCMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 009023 . This is a "SIHO / NCMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 000023031A . This is a "HUMANA / NCMA" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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