Provider Demographics
NPI:1740400431
Name:CONCOURSE REPLACEMENT LLC
Entity Type:Organization
Organization Name:CONCOURSE REPLACEMENT LLC
Other - Org Name:GRAND CONCOURSE DIALYSIS FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:LICCIARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-987-5942
Mailing Address - Street 1:97 NEW DORP LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-1796
Mailing Address - Country:US
Mailing Address - Phone:718-448-5641
Mailing Address - Fax:718-876-5969
Practice Address - Street 1:1780 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-5500
Practice Address - Country:US
Practice Address - Phone:718-583-1800
Practice Address - Fax:718-583-4160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02986203Medicaid
NY332642Medicare Oscar/Certification