Provider Demographics
NPI:1427394428
Name:EMPIRE STATE PHYSICIAN PLLC
Entity Type:Organization
Organization Name:EMPIRE STATE PHYSICIAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:R
Authorized Official - Last Name:HENRIQUES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-433-0205
Mailing Address - Street 1:11 RUSO DR
Mailing Address - Street 2:
Mailing Address - City:MENANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12204-1313
Mailing Address - Country:US
Mailing Address - Phone:518-433-0205
Mailing Address - Fax:
Practice Address - Street 1:180 WASHINGTON AVENUE EXT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-5304
Practice Address - Country:US
Practice Address - Phone:518-456-7831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231783207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02529371Medicaid
NY02529371Medicaid