Healthcare Provider Details

I. General information

NPI: 1114344348
Provider Name (Legal Business Name): ST LOUIS KIDNEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12855 N 40 DR SUITE 205
SAINT LOUIS MO
63141-8657
US

IV. Provider business mailing address

12855 N 40 DR SUITE 205
SAINT LOUIS MO
63141-8657
US

V. Phone/Fax

Practice location:
  • Phone: 314-720-0900
  • Fax: 314-579-0108
Mailing address:
  • Phone: 314-720-0900
  • Fax: 314-579-0108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAY SELTZER
Title or Position: AUTHORIZED MEMBER
Credential: M.D.
Phone: 314-825-0361