Basic Information
| Provider Information | |||||||||
| NPI: | 1053354100 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LONG ISLAND COMMUNITY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | PATCHOGUE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117724870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316547175 | ||||||||
| FaxNumber: | 6316547664 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | PATCHOGUE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117724870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316547175 | ||||||||
| FaxNumber: | 6316547664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 12/24/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FARRELL | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 6316547175 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/24/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000086 | 01 | NY | BLUE CROSS PROVIDER NO | OTHER | 00245529 | 05 | NY | MEDICAID |