NPIMap

Organization Active NPI

Island Rehabilitative Services Corp

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Staten Island, NY
National Provider Identifier
1669453502
Registry record updated Sep 28, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
License
7004204R Issued in NY
Legal business name
ISLAND REHABILITATIVE SERVICES CORP
Practice address
25 Fanning St
Staten Island, NY 10314-5307
Phone
(347) 671-8399
Fax
(347) 671-8398
NPI assigned
Nov 8, 2005
Organization subpart
Yes
Parent organization
ISLAND REHABILITATIVE SERVICES CORPAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Sep 28, 2011

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

Authorized official

Name
Mr. Dominic Licciardi
Title
Administrator
Phone
(718) 987-5942

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X 7004204R NY Primary

Addresses

Primary practice location

25 Fanning St
Staten Island, NY 10314-5307

Mailing address

97 New Dorp LN
Staten Island, NY 10306-2364
Phone (718) 448-5641

Other identifiers 2

IdentifierTypeStateIssuer
03004235MedicaidNY
00519755MedicaidNY

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20030915000008 NY Part A Provider - End-Stage Renal Disease Facility (ESRD) 7810808003 Practice locations: Staten Island, NY

Other NPIs with the same Medicare PAC ID 2

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

Care Compare: Dialysis facility

Medicare Care Compare
Listed as
Island Rehabilitative Services - Clove Lakes DialysisCCN 332638
Overall star rating
1.0 of 5
Ownership
Profit
Certified
Nov 7, 2003
Medicare certification status
ActiveFrom the Provider of Services file
Dialysis stations
8

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

National Provider Directory

National Provider Directory
Tax ID family
Island Rehabilitative Servicesbronx3 organizations share this tax ID, including this one
Part of
Island Rehabilitative Servicesbronx

Other organizations with this tax ID 2

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

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Affiliated clinicians 4

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": "1131408000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1317168000000",
    "number": "1669453502",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "97 NEW DORP LN",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103062364",
            "telephone_number": "718-448-5641",
            "fax_number": "718-876-5969"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "25 FANNING ST",
            "city": "STATEN ISLAND",
            "state": "NY",
            "postal_code": "103145307",
            "telephone_number": "347-671-8399",
            "fax_number": "347-671-8398"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ISLAND REHABILITATIVE SERVICES CORP",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ISLAND REHABILITATIVE SERVICES CORP",
        "enumeration_date": "2005-11-08",
        "last_updated": "2011-09-28",
        "status": "A",
        "authorized_official_last_name": "LICCIARDI",
        "authorized_official_first_name": "DOMINIC",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "718-987-5942",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": "NY",
            "license": "7004204R",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "03004235",
            "state": "NY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00519755",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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 Sep 28, 2011; 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.