MEDICARE: GATEWAY ST LOUIS DIALYSIS LLC

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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497074520
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GATEWAY ST LOUIS DIALYSIS LLC

Provider Business Mailing Address
First Line	:	4100 UNION BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63115-1225
Country	:	US
Telephone Number	:	314-382-3480
Fax Number	:	314-382-3515

Provider Business Practice Location Address
First Line	:	4100 UNION BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63115-1225
Country	:	US
Telephone Number	:	314-382-3480
Fax Number	:	314-382-3515

Authorized Official
Title or Position	:	CHIEF NURSING OFFICER
Name	:	SARA ANNE BRADY
Credential	:
Telephone Number	:	208-371-7878

Provider Enumeration Date	:	05/28/2010
Last Update Date	:	01/10/2023

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Directions to “GATEWAY ST LOUIS DIALYSIS LLC ” Practice Location

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