Healthcare Provider Details

I. General information

NPI: 1942451380
Provider Name (Legal Business Name): PD NEPHROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2008
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10004 KENNERLY RD SUITE 103A
SAINT LOUIS MO
63128-2173
US

IV. Provider business mailing address

10004 KENNERLY RD SUITE 103A
SAINT LOUIS MO
63128-2173
US

V. Phone/Fax

Practice location:
  • Phone: 314-543-5235
  • Fax: 314-543-5216
Mailing address:
  • Phone: 314-543-5235
  • Fax: 314-543-5216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License NumberLC0921675
License Number StateMO

VIII. Authorized Official

Name: DR. NABIL TAUK
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 314-543-5235