MEDICARE: ST. LOUIS NEPHROLOGY AND HYPERTENSION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RN0300X	Nephrology Physician	R9H62	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DG8471	OTHER	MO	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1174601124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. LOUIS NEPHROLOGY AND HYPERTENSION

Provider Business Mailing Address
First Line	:	PO BOX 797021
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63179-7000
Country	:	US
Telephone Number	:	314-644-3535
Fax Number	:

Provider Business Practice Location Address
First Line	:	2102 VADALABENE DR
Second Line	:
City	:	MARYVILLE
State	:	IL
Zip	:	62062-5632
Country	:	US
Telephone Number	:	618-288-1196
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. HENRY E PURCELL
Credential	:	M.D.
Telephone Number	:	314-276-7664

Provider Enumeration Date	:	11/01/2006
Last Update Date	:	09/10/2024

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