NPIMap

Organization Active NPI

Knickerbocker Dialysis Inc

Doing business as Ivy Dialysis

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Elmira, NY
National Provider Identifier
1386028843
Registry record updated Aug 8, 2024
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
Ivy Dialysis
Practice address
602 Ivy St
Elmira, NY 14905-1646
Phone
(607) 737-4186
Fax
(607) 737-4446
NPI assigned
Jul 15, 2015
Last updated
Aug 8, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 8, 2024

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

Authorized official

Name
Samuel Wey
Title
Assistant Secretary
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

602 Ivy St
Elmira, NY 14905-1646

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
04458935MedicaidNY

Other names 1

  • Ivy Dialysis Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150810001407 NY Part A Provider - End-Stage Renal Disease Facility (ESRD) 9436178191 Practice locations: Elmira, NY

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
DaVita Ivy DialysisCCN 332735
Overall star rating
3.0 of 5
Ownership
Profit
Certified
Jul 1, 2015
Medicare certification status
ActiveFrom the Provider of Services file
Chain
DaVita
Dialysis stations
20

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
33D2112825Ivy Dialysis602 Ivy Street, Elmira, NY 14905Certificate 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 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": "1436918400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1723075200000",
    "number": "1386028843",
    "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": "602 IVY ST",
            "city": "ELMIRA",
            "state": "NY",
            "postal_code": "149051646",
            "telephone_number": "607-737-4186",
            "fax_number": "607-737-4446"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KNICKERBOCKER DIALYSIS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-07-15",
        "last_updated": "2024-08-08",
        "certification_date": "2024-08-08",
        "status": "A",
        "authorized_official_last_name": "WEY",
        "authorized_official_first_name": "SAMUEL",
        "authorized_official_title_or_position": "ASSISTANT SECRETARY",
        "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": "04458935",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Ivy Dialysis",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Ivy Dialysis",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Elmira, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 8, 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.