Healthcare Provider Details

I. General information

NPI: 1902137425
Provider Name (Legal Business Name): ROBERT RODDY M.D. P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2010
Last Update Date: 01/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1690 UNIVERSITY AVE W #120
ST. PAUL MN
55104
US

IV. Provider business mailing address

1690 UNIVERSITY AVE W #120
ST. PAUL MN
55104
US

V. Phone/Fax

Practice location:
  • Phone: 651-999-0263
  • Fax: 651-999-0264
Mailing address:
  • Phone: 651-999-0263
  • Fax: 651-999-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number31580
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number31580
License Number StateMN

VIII. Authorized Official

Name: DR. ROBERT RODDY
Title or Position: PSYCHIATRY
Credential:
Phone: 651-999-0263