Basic Information
| Provider Information | |||||||||
| NPI: | 1922486182 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHN T MATHER MEMORIAL HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | BACK AND NECK PAIN CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 N COUNTRY RD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117772119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314731320 | ||||||||
| FaxNumber: | 6316867972 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 N COUNTRY RD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117772119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314731320 | ||||||||
| FaxNumber: | 6316867972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2015 | ||||||||
| LastUpdateDate: | 05/08/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DONNELLY | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROJECT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6314731320 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
No ID Information.