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General NPI Number Information
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NPI Number | 1215374954
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Entity Type | Organization
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Legal Business Name | SDR PSYCHIATRY LLC
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Dates
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Enumeration Date | 06/03/2013
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Last Update Date | 06/03/2013
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Provider Practice Location Address
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Address Line | 5200 WILLSON RD #405
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City | EDINA
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State | MN
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Zip | 55424-1332
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Country | US
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Telephone | 612-310-9960
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Fax | 612-872-2205
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Provider Business Mailing Address
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Address Line | PO BOX 24062 3948 W 49 1/2 STREET
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City | EDINA
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State | MN
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Zip | 55424-0062
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Country | US
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Telephone | 612-872-1500
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Fax | 612-872-2205
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Authorized Official
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Title or Position | PSYCHIATRIST
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Name | SILVIA DIVINETZ ROMERO
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Credential | MD
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Telephone | 612-872-1500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 24545
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License Number State | MN
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