NPIMap

Organization Active NPI

Dva Renal Healthcare Inc

Doing business as Effingham Dialysis

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Effingham, IL
National Provider Identifier
1245290782
Registry record updated Oct 21, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
License
N/A Issued in IL
Legal business name
DVA RENAL HEALTHCARE INC
Doing business as
Effingham Dialysis
Practice address
904 Medical Park Dr
Suite 1
Effingham, IL 62401-2193
Phone
(217) 342-9558
Fax
(217) 342-1049
NPI assigned
Mar 27, 2006
Last updated
Oct 21, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 21, 2024

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

Authorized official

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

Specialties & licenses 1

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

Addresses

Primary practice location

904 Medical Park Dr
Suite 1
Effingham, IL 62401-2193

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
2300487MedicaidOH

Other names 1

  • Effingham Dialysis Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20030414000000 IL Part A Provider - End-Stage Renal Disease Facility (ESRD) 0840107611 Practice locations: Effingham, IL

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
DaVita Effingham DialysisCCN 142580
Overall star rating
3.0 of 5
Ownership
Profit
Certified
Jan 1, 1998
Medicare certification status
ActiveFrom the Provider of Services file
Chain
DaVita
Dialysis stations
16

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
14D0723759Effingham Dialysis904 Medical Park Drive Suite 1, Effingham, IL 62401Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Gambro Healthcare Escon173 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 13

This tax ID family is large, so up to 24 of its organizations in the same state are linked here.

View all 13

Locations

904 Medical Park Dr
Ste 1
Effingham, IL 62401
Phone (217) 342-9558

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 3

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

NPI Registry JSON

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

{
    "created_epoch": "1143417600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1729468800000",
    "number": "1245290782",
    "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": "904 MEDICAL PARK DR",
            "address_2": "SUITE 1",
            "city": "EFFINGHAM",
            "state": "IL",
            "postal_code": "624012193",
            "telephone_number": "217-342-9558",
            "fax_number": "217-342-1049"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DVA RENAL HEALTHCARE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-03-27",
        "last_updated": "2024-10-21",
        "certification_date": "2024-10-21",
        "status": "A",
        "authorized_official_last_name": "WEY",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_middle_name": "T",
        "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": "IL",
            "license": "N/A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2300487",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Effingham Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Effingham Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Effingham, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 21, 2024; 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.