Healthcare Provider Details

I. General information

NPI: 1871912600
Provider Name (Legal Business Name): CITY PSYCHIATRIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4570 W 77TH ST #315
EDINA MN
55435-5008
US

IV. Provider business mailing address

4570 W 77TH ST #315
EDINA MN
55435-5008
US

V. Phone/Fax

Practice location:
  • Phone: 612-554-6794
  • Fax:
Mailing address:
  • Phone: 612-554-6794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number027457
License Number StateMN

VIII. Authorized Official

Name: NANCY KERMATH
Title or Position: OWNER
Credential: M.D.
Phone: 612-554-6794