Basic Information
| Provider Information | |||||||||
| NPI: | 1720091945 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUFFOLK COUNTY DEPT OF HEALTH SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BRENTWOOD MENTAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| 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: | 1841 BRENTWOOD RD | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117174625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6318537300 | ||||||||
| FaxNumber: | 6318537301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 10/22/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| 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 | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 00355019 | 05 | NY | MEDICAID |