Provider Demographics
NPI:1730593757
Name:ST LOUIS KIDNEY, LLC
Entity type:Organization
Organization Name:ST LOUIS KIDNEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:SLOAN
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-548-0265
Mailing Address - Street 1:PO BOX 78429
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63178-8429
Mailing Address - Country:US
Mailing Address - Phone:314-548-0265
Mailing Address - Fax:314-548-6555
Practice Address - Street 1:456 N NEW BALLAS RD STE 348
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6846
Practice Address - Country:US
Practice Address - Phone:314-548-0265
Practice Address - Fax:314-548-6555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-18
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500014637Medicaid