Provider Demographics
NPI:1386688646
Name:METRO HYPERTENSION & KIDNEY CENTER PC
Entity Type:Organization
Organization Name:METRO HYPERTENSION & KIDNEY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DONOVAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:POLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-432-2580
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:MARYLAND HEIGHTS
Mailing Address - State:MO
Mailing Address - Zip Code:63043-0449
Mailing Address - Country:US
Mailing Address - Phone:314-432-2580
Mailing Address - Fax:314-432-0223
Practice Address - Street 1:1400 US HIGHWAY 61 STE 240
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4141
Practice Address - Country:US
Practice Address - Phone:636-937-3337
Practice Address - Fax:636-931-7671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000155017174400000X
MOR5H69174400000X
207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MODC5238OtherRAILROAD MEDICARE
MODC5238OtherRAILROAD MEDICARE
MODC5238OtherRAILROAD MEDICARE
MOI20174Medicare UPIN
MO=========OtherTAX ID#