Healthcare Provider Details

I. General information

NPI: 1386688646
Provider Name (Legal Business Name): METRO HYPERTENSION & KIDNEY CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 03/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 US HIGHWAY 61 STE 240
FESTUS MO
63028-4141
US

IV. Provider business mailing address

PO BOX 1449
MARYLAND HEIGHTS MO
63043-0449
US

V. Phone/Fax

Practice location:
  • Phone: 636-937-3337
  • Fax: 636-931-7671
Mailing address:
  • Phone: 314-432-2580
  • Fax: 314-432-0223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number2000155017
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberR5H69
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DONOVAN C POLACK
Title or Position: MD
Credential:
Phone: 314-432-2580