Healthcare Provider Details

I. General information

NPI: 1710829098
Provider Name (Legal Business Name): DVA WASHINGTON UNIVERSITY HEALTHCARE OF GREATER ST LOUIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 FOREST PARK AVE
SAINT LOUIS MO
63108-2810
US

IV. Provider business mailing address

5200 VIRGINIA WAY LICENSURE AND CERTIFICATION DEPT
BRENTWOOD TN
37027-7569
US

V. Phone/Fax

Practice location:
  • Phone: 314-286-0842
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAM T WEY
Title or Position: VP, LICENSURE AND CERTIFICATION
Credential:
Phone: 615-341-6691