NPIMap

Organization Active NPI

Knickerbocker Dialysis Inc

Doing business as Staten Island Dialysis Center

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Staten Island, NY
National Provider Identifier
1366876948
Registry record updated Feb 29, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
License
7000272R Issued in NY
Legal business name
KNICKERBOCKER DIALYSIS INC
Doing business as
Staten Island Dialysis Center
Practice address
1139 Hylan Blvd
Staten Island, NY 10305-2061
Phone
(718) 816-4913
Fax
(718) 816-6340
NPI assigned
Aug 30, 2013
Last updated
Feb 29, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 29, 2024

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 7000272R NY Primary

Addresses

Primary practice location

1139 Hylan Blvd
Staten Island, NY 10305-2061

Mailing address

5200 Virginia Way
L & C Dept
Brentwood, TN 37027-7569
Phone (615) 341-6410

Other identifiers 1

IdentifierTypeStateIssuer
03911855MedicaidNY

Other names 1

  • Staten Island Dialysis Center Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20131203000434 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 Dialysis CenterCCN 332711
Overall star rating
4.0 of 5
Ownership
Profit
Certified
May 9, 2014
Medicare certification status
ActiveFrom the Provider of Services file
Chain
DaVita
Dialysis stations
18

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
33D2067682Staten Island Dialysis Center1139 Hylan Blvd, Staten Island, NY 10305Certificate 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 24

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

View all 24

Practitioners & affiliated clinicians

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": "1377820800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1709164800000",
    "number": "1366876948",
    "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",
            "telephone_number": "615-341-6410",
            "fax_number": "888-662-8259"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1139 HYLAN BLVD",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103052061",
            "telephone_number": "718-816-4913",
            "fax_number": "718-816-6340"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KNICKERBOCKER DIALYSIS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-08-30",
        "last_updated": "2024-02-29",
        "certification_date": "2024-02-29",
        "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": "NY",
            "license": "7000272R",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "03911855",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Staten Island Dialysis Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Staten Island Dialysis Center",
            "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 29, 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.