Provider Demographics
NPI:1821244757
Name:JOHN T MATHER MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:JOHN T MATHER MEMORIAL HOSPITAL
Other - Org Name:INTENSIVISTS
Other - Org Type:Other Name
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
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 1:75 N COUNTRY ROAD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2119
Mailing Address - Country:US
Mailing Address - Phone:631-473-1320
Mailing Address - Fax:
Practice Address - Street 1:75 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2119
Practice Address - Country:US
Practice Address - Phone:631-473-1320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JOHN T MATHER MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02859121Medicaid