Provider Demographics
NPI:1902137425
Name:ROBERT RODDY M.D. P.A.
Entity type:Organization
Organization Name:ROBERT RODDY M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRY
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:RODDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-999-0263
Mailing Address - Street 1:1690 UNIVERSITY AVE W
Mailing Address - Street 2:#120
Mailing Address - City:ST. PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-999-0263
Mailing Address - Fax:651-999-0264
Practice Address - Street 1:1690 UNIVERSITY AVE W
Practice Address - Street 2:#120
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-999-0263
Practice Address - Fax:651-999-0264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN315802084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN459888100Medicaid
MN459888100Medicaid