Provider Demographics
NPI:1598945735
Name:BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER
Entity Type:Organization
Organization Name:BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER
Other - Org Name:BROOKHAVEN MEMORIAL HOSPITAL CENTER FOR WOUND CARE
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:631-687-4199
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?:Yes
Parent Organization LBN:BROOKHAVEN MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-05
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWKW881Medicare PIN