Basic Information
Provider Information | |||||||||
NPI: | 1104920313 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUFFOLK COUNTY DEPT OF HEALTH SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RIVERHEAD MENTAL HEALTH CLINIC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3500 SUNRISE HWY | ||||||||
Address2: | SUITE 124, PO BOX 9006 | ||||||||
City: | GREAT RIVER | ||||||||
State: | NY | ||||||||
PostalCode: | 117391001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6318540196 | ||||||||
FaxNumber: | 6318540198 | ||||||||
Practice Location | |||||||||
Address1: | 300 CENTER DR | ||||||||
Address2: |   | ||||||||
City: | RIVERHEAD | ||||||||
State: | NY | ||||||||
PostalCode: | 119013393 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6318521440 | ||||||||
FaxNumber: | 6318521448 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/08/2006 | ||||||||
LastUpdateDate: | 10/22/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TOMARKEN | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | COMMISSIONER | ||||||||
AuthorizedOfficialTelephone: | 6318540100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 6919109A | NY | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 00688179 | 05 | NY |   | MEDICAID |