MEDICARE: METRO ST. LOUIS DIALYSIS - FLORISSANT 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	:	1942363320
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METRO ST. LOUIS DIALYSIS - FLORISSANT LLC

Provider Business Mailing Address
First Line	:	10160 W FLORISSANT AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-2104
Country	:	US
Telephone Number	:	314-869-4978
Fax Number	:	314-869-5098

Provider Business Practice Location Address
First Line	:	10160 W FLORISSANT AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-2104
Country	:	US
Telephone Number	:	314-869-4978
Fax Number	:	314-869-5098

Authorized Official
Title or Position	:	VP OF CLINICAL & REGULATORY
Name	:	KEISHA DENISE GREENE
Credential	:
Telephone Number	:	978-522-3905

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	08/18/2022

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