Basic Information
| Provider Information | |||||||||
| NPI: | 1154550812 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EMPIRE MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2693 E WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911071412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267988600 | ||||||||
| FaxNumber: | 6267988842 | ||||||||
| Practice Location | |||||||||
| Address1: | 1906 COMMERCENTER E | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267988600 | ||||||||
| FaxNumber: | 6267988842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 11/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | JAYASHINGHE | ||||||||
| AuthorizedOfficialFirstName: | WALTER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9512807700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.