MEDICARE: DVA WASHINGTON UNIVERSITY HEALTHCARE OF GREATER ST LOUIS 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

General Provider Information

NPI Number	:	1962344234
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DVA WASHINGTON UNIVERSITY HEALTHCARE OF GREATER ST LOUIS LLC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	LICENSURE AND CERTIFICATION DEPT
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	272 MAYFAIR PLAZA SHOPPING CTR
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63033-8009
Country	:	US
Telephone Number	:	314-859-1234
Fax Number	:

Authorized Official
Title or Position	:	VP, LICENSURE AND CERTIFICATION
Name	:	SAM T WEY
Credential	:
Telephone Number	:	615-341-6691

Provider Enumeration Date	:	04/07/2026
Last Update Date	:	04/07/2026

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