Provider Demographics
NPI:1093130742
Name:EMPIRE WOUND PHYSICIAN SERVICES, PLLC
Entity type:Organization
Organization Name:EMPIRE WOUND PHYSICIAN SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:ILANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-534-1775
Mailing Address - Street 1:6150 PARKLAND BLVD STE 225
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-4103
Mailing Address - Country:US
Mailing Address - Phone:216-273-9800
Mailing Address - Fax:216-273-9998
Practice Address - Street 1:170 LAKE ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-1966
Practice Address - Country:US
Practice Address - Phone:216-273-9800
Practice Address - Fax:216-273-9998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-04
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04025343Medicaid