Provider Demographics
NPI:1942363320
Name:METRO ST. LOUIS DIALYSIS - FLORISSANT LLC
Entity Type:Organization
Organization Name:METRO ST. LOUIS DIALYSIS - FLORISSANT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF CLINICAL & REGULATORY
Authorized Official - Prefix:
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-522-3905
Mailing Address - Street 1:10160 W FLORISSANT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63136-2104
Mailing Address - Country:US
Mailing Address - Phone:314-869-4978
Mailing Address - Fax:314-869-5098
Practice Address - Street 1:10160 W FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-2104
Practice Address - Country:US
Practice Address - Phone:314-869-4978
Practice Address - Fax:314-869-5098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2022-08-18
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
MO506121102Medicaid
MO506121102Medicaid