Provider Demographics
NPI:1497074520
Name:GATEWAY ST LOUIS DIALYSIS LLC
Entity Type:Organization
Organization Name:GATEWAY ST LOUIS DIALYSIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF NURSING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-371-7878
Mailing Address - Street 1:4100 UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115-1225
Mailing Address - Country:US
Mailing Address - Phone:314-382-3480
Mailing Address - Fax:314-382-3515
Practice Address - Street 1:4100 UNION BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-1225
Practice Address - Country:US
Practice Address - Phone:314-382-3480
Practice Address - Fax:314-382-3515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-28
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO149774520Medicaid
MO262642Medicare Oscar/Certification