1104823996 NPI number — BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER, INC.

Table of content: (NPI 1104823996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104823996 NPI number — BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104823996
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 WEST MAIN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PATCHOGUE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11772-3003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-758-3600
Provider Business Mailing Address Fax Number:
631-758-3615

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 WEST MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PATCHOGUE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11772-3003
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-758-3600
Provider Business Practice Location Address Fax Number:
631-758-3615
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FARRELL
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
VICE PRESIDENT & CFO
Authorized Official Telephone Number:
631-654-7175

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  5123600 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000086 . This is a "EMPIRE BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00245529 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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