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General NPI Number Information
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NPI Number | 1528131380
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Entity Type | Organization
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Legal Business Name | SOUTHDALE OTOLARYNGOLOGY PA
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Dates
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Enumeration Date | 11/17/2006
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Last Update Date | 06/06/2011
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Provider Practice Location Address
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Address Line | 7373 FRANCE AVENUE S STE 302
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City | EDINA
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State | MN
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Zip | 55435-4538
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Country | US
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Telephone | 952-896-3166
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Fax | 952-896-9853
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Provider Business Mailing Address
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Address Line | 7373 FRANCE AVENUE S STE 302
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City | EDINA
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State | MN
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Zip | 55435-4538
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Country | US
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Telephone | 952-896-3166
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Fax | 952-896-9853
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Authorized Official
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Title or Position | PRESIDENT
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Name | ROBERT H ROSENBERG
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Credential | MD
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Telephone | 952-896-3166
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | PF128
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License Number State | MN
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