Basic Information
| Provider Information | |||||||||
| NPI: | 1902029796 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROOKHAVEN MEMORIAL HOSPITAL HEALTH CENTER EAST | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 HOSPITAL ROAD | ||||||||
| Address2: | |||||||||
| City: | PATCHOGUE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117724870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6316547100 | ||||||||
| FaxNumber: | 5163331075 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 MONTAUK HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | SHIRLEY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119672114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314903040 | ||||||||
| FaxNumber: | 6313956340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 05/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | FARRELL | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT & CFO | ||||||||
| AuthorizedOfficialTelephone: | 6316547175 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER | ||||||||
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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 | 00245529 | 05 | NY | MEDICAID |