Basic Information
| Provider Information | |||||||||
| NPI: | 1366816894 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN T MATHER MEMORIAL HOSPITAL | ||||||||
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| OtherOrganizationName: | BARIATRIC GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 HIGHLANDS BLVD | ||||||||
| Address2: | BOX 9 | ||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117772320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316867809 | ||||||||
| FaxNumber: | 6316867972 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 N COUNTRY RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117772119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316890220 | ||||||||
| FaxNumber: | 6314173042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2015 | ||||||||
| LastUpdateDate: | 04/08/2016 | ||||||||
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| AuthorizedOfficialLastName: | WISNOSKI | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6314731320 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RB0002X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Bariatric Medicine |
No ID Information.