Healthcare Provider Details

I. General information

NPI: 1730593757
Provider Name (Legal Business Name): ST LOUIS KIDNEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 N NEW BALLAS RD STE 348
CREVE COEUR MO
63141-6846
US

IV. Provider business mailing address

PO BOX 78429
SAINT LOUIS MO
63178-8429
US

V. Phone/Fax

Practice location:
  • Phone: 314-548-0265
  • Fax: 314-548-6555
Mailing address:
  • Phone: 314-548-0265
  • Fax: 314-548-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DEREK SLOAN LARSON
Title or Position: OWNER
Credential: MD
Phone: 314-548-0265