Healthcare Provider Details

I. General information

NPI: 1003188020
Provider Name (Legal Business Name): EMPIRE GATE MEDICAL P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 05/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8810 PARSONS BLVD
JAMAICA NY
11432-3842
US

IV. Provider business mailing address

111 BROADWAY #1005
NEW YORK NY
10006-1951
US

V. Phone/Fax

Practice location:
  • Phone: 718-291-8111
  • Fax: 718-487-9343
Mailing address:
  • Phone: 646-217-4610
  • Fax: 917-591-8596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number163293
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT GORDON
Title or Position: COO
Credential:
Phone: 646-217-4610