Provider Demographics
NPI:1427267855
Name:MISSOURI RENAL MEDICINE
Entity type:Organization
Organization Name:MISSOURI RENAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ROBYN
Authorized Official - Middle Name:H
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-251-6344
Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 3015B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6344
Mailing Address - Fax:314-251-7929
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 3015B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6344
Practice Address - Fax:314-251-7929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506877000Medicaid
MOCP8380OtherRAILROAD MEDICARE
MO000011536Medicare PIN
MOCP8380OtherRAILROAD MEDICARE