Basic Information
| Provider Information | |||||||||
| NPI: | 1093718728 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN T. MATHER MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 N COUNTRY RD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117772190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314731320 | ||||||||
| FaxNumber: | 6314735254 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 N COUNTRY RD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117772119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314731320 | ||||||||
| FaxNumber: | 6316861459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | WISNOSKI | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP-FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6314762753 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 5149000 | NY | N | Hospital Units | Psychiatric Unit | 314000000X | 5149000 | NY | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 282N00000X | 5149000 | NY | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 100822 | 05 | WA | MEDICAID | 00274364 | 05 | NY | MEDICAID | 3300185 | 05 | NC | MEDICAID | HSP32196 | 05 | CA | MEDICAID | HSP42196 | 05 | CA | MEDICAID | 3044310 | 05 | CT | MEDICAID | 110851658 | 05 | PA | MEDICAID | 1206575 | 05 | MA | MEDICAID | 21920 | 05 | MD | MEDICAID | 6004504 | 05 | NJ | MEDICAID |