Healthcare Provider Details

I. General information

NPI: 1255962783
Provider Name (Legal Business Name): EMPIRE STATE RADIOLOGY P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONTAUK HWY
WEST ISLIP NY
11795-4927
US

IV. Provider business mailing address

PO BOX 784407
PHILADELPHIA PA
19178-4407
US

V. Phone/Fax

Practice location:
  • Phone: 718-223-4685
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN VAUGHN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 629-317-1465