Provider Demographics
NPI:1508003716
Name:BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER, INC.
Other - Org Name:DIABETES WELLNESS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:VICE PRESIDENT & CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-654-7175
Mailing Address - Street 1:101 HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4870
Mailing Address - Country:US
Mailing Address - Phone:631-654-7100
Mailing Address - Fax:
Practice Address - Street 1:33 MEDFORD AVENUE
Practice Address - Street 2:SUITE D
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1222
Practice Address - Country:US
Practice Address - Phone:631-687-4190
Practice Address - Fax:631-687-4199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-09
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital