Provider Demographics
NPI:1104881572
Name:RITTENOUR, TIMOTHY MARK (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:MARK
Last Name:RITTENOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 LABREE AVE N STE 8
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-2020
Mailing Address - Country:US
Mailing Address - Phone:218-683-5118
Mailing Address - Fax:218-683-5228
Practice Address - Street 1:309 LABREE AVE N STE 8
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2020
Practice Address - Country:US
Practice Address - Phone:218-683-5118
Practice Address - Fax:218-683-5228
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33334208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
E57374Medicare UPIN
089000981Medicare ID - Type Unspecified