Provider Demographics
NPI:1568774453
Name:JOHN T. MATHER MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JOHN T. MATHER MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
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 1:625 BELLE TERRE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2316
Mailing Address - Country:US
Mailing Address - Phone:631-686-7689
Mailing Address - Fax:
Practice Address - Street 1:5505 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:MOUNT SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766-2037
Practice Address - Country:US
Practice Address - Phone:631-686-7689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-08
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03246297Medicaid
NYA100034823Medicare PIN