Provider Demographics
NPI:1114014065
Name:BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER
Entity Type:Organization
Organization Name:BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER
Other - Org Name:BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:S
Authorized Official - Last Name:SCHWARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-654-7728
Mailing Address - Street 1:P.O. BOX 22027
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12201-2027
Mailing Address - Country:US
Mailing Address - Phone:631-321-8043
Mailing Address - Fax:631-321-4235
Practice Address - Street 1:101 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772
Practice Address - Country:US
Practice Address - Phone:631-654-7728
Practice Address - Fax:631-447-3698
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-10
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02198121Medicaid
NY02198121Medicaid