Provider Demographics
NPI:1154550812
Name:EMPIRE MEDICAL GROUP, INC
Entity type:Organization
Organization Name:EMPIRE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:JAYASHINGHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-280-7700
Mailing Address - Street 1:2693 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1412
Mailing Address - Country:US
Mailing Address - Phone:626-798-8600
Mailing Address - Fax:626-798-8842
Practice Address - Street 1:1906 COMMERCENTER E
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3422
Practice Address - Country:US
Practice Address - Phone:626-798-8600
Practice Address - Fax:626-798-8842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-02
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center