Provider Demographics
NPI:1952177057
Name:EMPIRE STATE MEDICAL PC
Entity Type:Organization
Organization Name:EMPIRE STATE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:THEAGENE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-270-8353
Mailing Address - Street 1:PO BOX 120328
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-0328
Mailing Address - Country:US
Mailing Address - Phone:347-270-8353
Mailing Address - Fax:347-826-1917
Practice Address - Street 1:10649 SUTPHIN BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-5135
Practice Address - Country:US
Practice Address - Phone:929-393-1966
Practice Address - Fax:929-755-4044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty