Provider Demographics
NPI:1588625032
Name:DVA WASHINGTON UNIVERSITY HEALTHCARE OF GREATER ST LOUIS LLC
Entity Type:Organization
Organization Name:DVA WASHINGTON UNIVERSITY HEALTHCARE OF GREATER ST LOUIS LLC
Other - Org Name:ST LOUIS WEST DIALYSIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIRECTOR LICENSURE&CERTIFICATION
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-341-6641
Mailing Address - Street 1:5200 VIRGINIA WAY
Mailing Address - Street 2:L&C DEPT
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7569
Mailing Address - Country:US
Mailing Address - Phone:615-341-6264
Mailing Address - Fax:800-297-2925
Practice Address - Street 1:400 N LINDBERGH BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7814
Practice Address - Country:US
Practice Address - Phone:314-989-0886
Practice Address - Fax:314-989-0596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-31
Last Update Date:2023-10-11
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
MO505143602Medicaid
OH2300450Medicaid
MO505143602Medicaid
262583Medicare Oscar/Certification