NPIMap

Organization Active NPI

Knickerbocker Dialysis Inc

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • Queens Village, NY
National Provider Identifier
1770528432
Registry record updated Jul 16, 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
Practice address
22202 Hempstead Ave
Ste 170
Queens Village, NY 11429-2123
Phone
(718) 217-6200
Fax
(718) 217-4191
NPI assigned
Jun 18, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 16, 2025

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 Primary

Addresses

Primary practice location

22202 Hempstead Ave
Ste 170
Queens Village, NY 11429-2123

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
03055098MedicaidNY

Other names 1

  • Queens Village 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
O20051114000530 NY Part A Provider - End-Stage Renal Disease Facility (ESRD) 9436178191 Practice locations: Queens Village, NY

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
33D1028973Queens Village Dialysis Center22202 Hempstead Ave - Suite 170, Queens Village, NY 11429Certificate 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

Locations

22202 Hempstead Ave
Ste 170
Queens Village, NY 11429
Phone (718) 217-6200

NPI Registry JSON

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

{
    "created_epoch": "1150588800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1752624000000",
    "number": "1770528432",
    "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": "22202 HEMPSTEAD AVE",
            "address_2": "STE 170",
            "city": "QUEENS VILLAGE",
            "state": "NY",
            "postal_code": "114292123",
            "telephone_number": "718-217-6200",
            "fax_number": "718-217-4191"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "KNICKERBOCKER DIALYSIS INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-18",
        "last_updated": "2025-07-16",
        "certification_date": "2025-07-16",
        "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": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "03055098",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Queens Village Dialysis Center",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Queens Village Dialysis Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Queens Village, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 16, 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.