Provider Demographics
NPI:1013383520
Name:WORKMENS CIRCLE DIALYSIS MANAGEMENT LLC
Entity Type:Organization
Organization Name:WORKMENS CIRCLE DIALYSIS MANAGEMENT LLC
Other - Org Name:WORKMENS CIRCLE DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER / MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBENEDICTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-422-7818
Mailing Address - Street 1:3155 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-3134
Mailing Address - Country:US
Mailing Address - Phone:718-304-1255
Mailing Address - Fax:
Practice Address - Street 1:3155 GRACE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-3134
Practice Address - Country:US
Practice Address - Phone:718-304-1255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
332695OtherCCN
NY03760249Medicaid