Provider Demographics
NPI:1073863635
Name:JOHN T. MATHER MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JOHN T. MATHER MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO, VP- FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:WISNOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-473-1320
Mailing Address - Street 1:625 BELLE TERRE ROAD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 NORTH COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2190
Practice Address - Country:US
Practice Address - Phone:631-473-1320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225349-1207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Single Specialty