Healthcare Provider Details

I. General information

NPI: 1750690806
Provider Name (Legal Business Name): EMPIRE NY MEDICAL CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2010
Last Update Date: 10/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

928 BROADWAY SUITE 304
NEW YORK NY
10010-6008
US

IV. Provider business mailing address

3731 73RD ST APT 6F
JACKSON HEIGHTS NY
11372-6250
US

V. Phone/Fax

Practice location:
  • Phone: 646-688-3145
  • Fax:
Mailing address:
  • Phone: 917-488-4670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number258181
License Number StateNY

VIII. Authorized Official

Name: WEYMIN GUILLERMO HAGO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 646-688-3145