Basic Information
| Provider Information | |||||||||
| NPI: | 1619912797 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LOUIS NEPHROLOGY ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840132 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641840132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148433449 | ||||||||
| FaxNumber: | 3148438762 | ||||||||
| Practice Location | |||||||||
| Address1: | 10004 KENNERLY RD | ||||||||
| Address2: | SUITE 315 A | ||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148433449 | ||||||||
| FaxNumber: | 3148438762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 12/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | QUADIR | ||||||||
| AuthorizedOfficialFirstName: | HUMAYUN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3148433449 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | R7576 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | CS0823 | 01 | RAILROAD MEDICARE | OTHER |