Organization
PREMIER DIALYSIS OF WEST COUNTY, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. HAROLD GOLDAMMER JR. (PRESIDENT)
(618) 407-2153
Entity
Organization
Contact information
Practice address
13190 S OUTER 40, TOWN AND COUNTRY, MO 63017-5917
(314) 424-3330
(314) 485-3049
Mailing address
132 FOX HILL CT, EDWARDSVILLE, IL 62025-5736
(618) 655-0422
(618) 655-0423
Taxonomy
Speciality
Code
Description
License number
State
261QE0700X
End-Stage Renal Disease (ESRD) Treatment Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
219086
ANTHEM BLUE CROSS
MO
05
—
507429801
—
MO
Enumeration date
03/22/2007
Last updated
12/10/2008
Update your record
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