Provider Demographics
NPI:1366816894
Name:JOHN T MATHER MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JOHN T MATHER MEMORIAL HOSPITAL
Other - Org Name:BARIATRIC GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:
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 1:100 HIGHLANDS BLVD
Mailing Address - Street 2:BOX 9
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2320
Mailing Address - Country:US
Mailing Address - Phone:631-686-7809
Mailing Address - Fax:631-686-7972
Practice Address - Street 1:75 N COUNTRY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2119
Practice Address - Country:US
Practice Address - Phone:631-689-0220
Practice Address - Fax:631-417-3042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-20
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Single Specialty