Provider Demographics
NPI:1265844716
Name:JOHN T MATHER MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JOHN T MATHER MEMORIAL HOSPITAL
Other - Org Name:MEDICAL WEIGHT MANAGEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position: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:CFO
Authorized Official - Phone:631-473-1320
Mailing Address - Street 1:625 BELLE TERRE RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2316
Mailing Address - Country:US
Mailing Address - Phone:631-686-7897
Mailing Address - Fax:631-686-2503
Practice Address - Street 1:625 BELLE TERRE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2316
Practice Address - Country:US
Practice Address - Phone:631-686-7897
Practice Address - Fax:631-686-2503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-02
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty