Provider Demographics
NPI:1396945168
Name:ST. CHARLES NEPHROLOGY
Entity type:Organization
Organization Name:ST. CHARLES NEPHROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRIKAS
Authorized Official - Middle Name:I
Authorized Official - Last Name:JUKNIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-928-0123
Mailing Address - Street 1:6 JUNGERMANN CIR
Mailing Address - Street 2:SUITE 215
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1621
Mailing Address - Country:US
Mailing Address - Phone:636-928-0123
Mailing Address - Fax:636-928-0129
Practice Address - Street 1:6 JUNGERMANN CIR
Practice Address - Street 2:SUITE 215
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1621
Practice Address - Country:US
Practice Address - Phone:636-928-0123
Practice Address - Fax:636-928-0129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000158727207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG04248Medicare UPIN