NPIMap

Organization Active NPI

Renal Treatment Centers Northeast Inc

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Philadelphia, PA
National Provider Identifier
1104095041
Registry record updated Jan 6, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
Legal business name
RENAL TREATMENT CENTERS NORTHEAST INC
Practice address
1172 S Broad St
Philadelphia, PA 19146-3142
Phone
(215) 875-6720
Fax
(215) 875-6721
NPI assigned
Feb 25, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 6, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Samuel Wey
Title
VP, Licensure & Certification
Phone
(615) 341-6641

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X Primary

Addresses

Primary practice location

1172 S Broad St
Philadelphia, PA 19146-3142

Mailing address

5200 Virginia Way
L&C Dept
Brentwood, TN 37027-7569

Other identifiers 1

IdentifierTypeStateIssuer
100729430 0033MedicaidPA

Other names 1

  • South Broad Street Dialysis Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080430000244 PA Part A Provider - End-Stage Renal Disease Facility (ESRD) 9335057801 Practice locations: Philadelphia, PA

National Provider Directory

National Provider Directory
Tax ID family
Renal Treatment CTRS No13 organizations share this tax ID, including this one

Other organizations with this tax ID 12

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

Other NPIs with the same Medicare PAC ID 11

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Affiliated clinicians 3

Clinicians who list this facility as an affiliation in Medicare Care Compare.

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
DaVita South Broad Street DialysisCCN 392753
Overall star rating
1.0 of 5
Ownership
Profit
Certified
Feb 11, 2009
Medicare certification status
ActiveFrom the Provider of Services file
Chain
DaVita
Dialysis stations
24

Name & address match This facility record has no NPI; it was connected to this NPI by matching name and address.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
39D1090639South Broad Street Dialysis1172 South Broad Street, Philadelphia, PA 19146Certificate of waiverOct 15, 2026

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1203897600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1736121600000",
    "number": "1104095041",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5200 VIRGINIA WAY",
            "address_2": "L&C DEPT",
            "city": "BRENTWOOD",
            "state": "TN",
            "postal_code": "370277569"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1172 S BROAD ST",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191463142",
            "telephone_number": "215-875-6720",
            "fax_number": "215-875-6721"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RENAL TREATMENT CENTERS NORTHEAST INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-02-25",
        "last_updated": "2025-01-06",
        "certification_date": "2025-01-06",
        "status": "A",
        "authorized_official_last_name": "WEY",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "VP, LICENSURE & CERTIFICATION",
        "authorized_official_telephone_number": "615-341-6641"
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100729430 0033",
            "state": "PA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "South Broad Street Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "South Broad Street Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Philadelphia, PA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 6, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.