MEDICARE: KNICKERBOCKER DIALYSIS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962957993
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KNICKERBOCKER DIALYSIS INC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	L & C DEPT
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2331 EASTCHESTER RD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10469-5910
Country	:	US
Telephone Number	:	718-547-0612
Fax Number	:	718-653-0294

Authorized Official
Title or Position	:	VP LICENSURE & CERTIFICATION
Name	:	SAMUEL WEY
Credential	:
Telephone Number	:	615-341-6641

Provider Enumeration Date	:	08/19/2016
Last Update Date	:	10/09/2024

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