Provider Demographics
NPI:1255573358
Name:ROBERT J SEVENICH M.D.,J.D.,P.A.
Entity type:Organization
Organization Name:ROBERT J SEVENICH M.D.,J.D.,P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:POLSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-444-8512
Mailing Address - Street 1:855 VILLAGE CENTER DR STE 181
Mailing Address - Street 2:
Mailing Address - City:NORTH OAKS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-3016
Mailing Address - Country:US
Mailing Address - Phone:651-444-8512
Mailing Address - Fax:651-414-0279
Practice Address - Street 1:1714 HOWARD ST N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-4842
Practice Address - Country:US
Practice Address - Phone:612-509-5522
Practice Address - Fax:651-414-0279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN903318100Medicaid
MNF77576Medicare UPIN
MN903318100Medicaid