JOHN T. MATHER MEMORIAL HOSPITAL

Provider Demographics

• NPI: 1093718728
• Name: JOHN T. MATHER MEMORIAL HOSPITAL
• Entity Type: Organization
• Organization Name: JOHN T. MATHER MEMORIAL HOSPITAL
• Authorized Official - Title/Position: VP-FINANCE
• Authorized Official - Prefix: MR
• Authorized Official - First Name: JOSEPH
• Authorized Official - Middle Name: J
• Authorized Official - Last Name: WISNOSKI
• Authorized Official - Phone: 631-476-2753
• Mailing Address - Street 1: 75 N COUNTRY RD
• Mailing Address - City: PORT JEFFERSON
• Mailing Address - State: NY
• Mailing Address - Zip Code: 11777-2190
• Mailing Address - Country: US
• Mailing Address - Phone: 631-473-1320
• Mailing Address - Fax: 631-473-5254
• Practice Address - Street 1: 75 N COUNTRY RD
• Practice Address - City: PORT JEFFERSON
• Practice Address - State: NY
• Practice Address - Zip Code: 11777-2119
• Practice Address - Country: US
• Practice Address - Phone: 631-473-1320
• Practice Address - Fax: 631-686-1459
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2005-05-27
• Last Update Date: 2020-10-06

Provider Licenses

State	License ID	Taxonomies
NY	5149000	273R00000X, 282N00000X, 314000000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	282N00000X	Hospitals	General Acute Care Hospital
No	273R00000X	Hospital Units	Psychiatric Unit
No	314000000X	Nursing & Custodial Care Facilities	Skilled Nursing Facility

Provider Identifiers

State	Identifier ID	ID Type	Issuer
WA	100822	Medicaid
NY	00274364	Medicaid
NC	3300185	Medicaid
CA	HSP32196	Medicaid
CA	HSP42196	Medicaid
CT	3044310	Medicaid
PA	110851658	Medicaid
MA	1206575	Medicaid
MD	21920	Medicaid
NJ	6004504	Medicaid
CA	HSP32196	Medicaid
NJ	6004504	Medicaid
NY	33S185	Medicare Oscar/Certification
NY	335853	Medicare Oscar/Certification
NY	W72931	Medicare ID - Type Unspecified	PUL. FUNCTION 1500 BILLIN
NY	W7292	Medicare ID - Type Unspecified	STRESS 1500 BILLING
NY	JOW60401	Medicare ID - Type Unspecified	1500 BILLING NO.
WA	100822	Medicaid