Basic Information
| Provider Information | |||||||||
| NPI: | 1669434544 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DVA WASHINGTON UNIVERSITY HEALTHCARE OF GREATER ST. LOUIS LLC | ||||||||
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| OtherOrganizationName: | DEBALIVIERE DIALYSIS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | L&C DEPT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153416264 | ||||||||
| FaxNumber: | 8002972925 | ||||||||
| Practice Location | |||||||||
| Address1: | 324 DE BALIVIERE AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631121804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143679111 | ||||||||
| FaxNumber: | 3143679248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 01/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | WINSTEL | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 502928005 | 05 | MO | MEDICAID | 200569640A | 05 | KS | MEDICAID |