Basic Information
| Provider Information | |||||||||
| NPI: | 1902841513 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KNICKERBOCKER DIALYSIS INC | ||||||||
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| OtherOrganizationName: | PORT WASHINGTON DIALYSIS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 VIRGINIA WAY | ||||||||
| Address2: | L&C DEPT | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370277569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153204414 | ||||||||
| FaxNumber: | 8668652884 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 SEAVIEW BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT WASHINGTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110504618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164843460 | ||||||||
| FaxNumber: | 5164847949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| AuthorizedOfficialLastName: | HILGER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2537334500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
ID Information
| ID | Type | State | Issuer | Description | 03049052 | 05 | NY | MEDICAID |