Basic Information
Provider Information | |||||||||
NPI: | 1598945735 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BROOKHAVEN MEMORIAL HOSPITAL CENTER FOR WOUND CARE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 HOSPITAL ROAD | ||||||||
Address2: |   | ||||||||
City: | PATCHOGUE | ||||||||
State: | NY | ||||||||
PostalCode: | 117724870 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6316547100 | ||||||||
FaxNumber: | 6316874199 | ||||||||
Practice Location | |||||||||
Address1: | 33 MEDFORD AVENUE | ||||||||
Address2: | SUITE D | ||||||||
City: | PATCHOGUE | ||||||||
State: | NY | ||||||||
PostalCode: | 117721222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6316874190 | ||||||||
FaxNumber: | 6316874199 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/05/2007 | ||||||||
LastUpdateDate: | 06/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FARRELL | ||||||||
AuthorizedOfficialFirstName: | BRENDA | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & CFO | ||||||||
AuthorizedOfficialTelephone: | 6316547175 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BROOKHAVEN MEMORIAL HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/02/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0800X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Recovery Care |
No ID Information.