Healthcare Provider Details

I. General information

NPI: 1346462629
Provider Name (Legal Business Name): SERGE SOMROV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 MINNESOTA DR STE 800
EDINA MN
55435-7915
US

IV. Provider business mailing address

3600 MINNESOTA DR STE 800
EDINA MN
55435-7915
US

V. Phone/Fax

Practice location:
  • Phone: 952-595-1301
  • Fax: 612-294-4903
Mailing address:
  • Phone: 952-595-1301
  • Fax: 612-294-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number235434
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number235434
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number235434-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: