Provider Demographics
NPI:1285024919
Name:EMPIRE MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:EMPIRE MEDICAL ASSOCIATES PC
Other - Org Name:EMPIRE MEDICAL ASSOCIATES BELLEVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-964-1506
Mailing Address - Street 1:5626 OBERLIN DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 FRANKLIN AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-3532
Practice Address - Country:US
Practice Address - Phone:973-759-1221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDVANTX, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09044800332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site