NPIMap

Organization Active NPI

Knickerbocker Dialysis Inc

Doing business as Staten Island South Dialysis

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Staten Island, NY
National Provider Identifier
1245731876
Registry record updated Feb 24, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
Legal business name
KNICKERBOCKER DIALYSIS INC
Doing business as
Staten Island South Dialysis
Practice address
30 Sneden Ave
Staten Island, NY 10312-3637
Phone
(718) 356-2678
Fax
(718) 356-6376
NPI assigned
Feb 28, 2018
Last updated
Feb 24, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 24, 2025

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 NU Primary

Addresses

Primary practice location

30 Sneden Ave
Staten Island, NY 10312-3637

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
05821045MedicaidNY

Other names 1

  • Staten Island South Dialysis Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180326001070 NY Part A Provider - End-Stage Renal Disease Facility (ESRD) 9436178191 Practice locations: Staten Island, NY

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
DaVita Staten Island South DialysisCCN 332799
Overall star rating
5.0 of 5
Ownership
Profit
Certified
Sep 25, 2019
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
33D2162376Staten Island South Dialysis30 Sneden Ave, Staten Island, NY 10312Certificate of waiverMar 26, 2027

National Provider Directory

National Provider Directory
Tax ID family
Knickerbocker Dialysis Inc65 organizations share this tax ID, including this one

Organizations with this tax ID in the same state 23

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

View all 23

Practitioners & affiliated clinicians

Affiliated clinicians 2

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": "1519776000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1740355200000",
    "number": "1245731876",
    "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": "30 SNEDEN AVE",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103123637",
            "telephone_number": "718-356-2678",
            "fax_number": "718-356-6376"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KNICKERBOCKER DIALYSIS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-02-28",
        "last_updated": "2025-02-24",
        "certification_date": "2025-02-24",
        "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": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "05821045",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Staten Island South Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Staten Island, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 24, 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.