Provider Demographics
NPI:1851321152
Name:COUNTY OF SUFFOLK
Entity Type:Organization
Organization Name:COUNTY OF SUFFOLK
Other - Org Name:BRENTWOOD FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COMMISSIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:TOMARKEN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW,MPH,MBA,FRCPC,FA
Authorized Official - Phone:631-854-0100
Mailing Address - Street 1:3500 SUNRISE HWY, SUITE 124
Mailing Address - Street 2:P.O. BOX 9006
Mailing Address - City:GREAT RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11739-9006
Mailing Address - Country:US
Mailing Address - Phone:631-854-0000
Mailing Address - Fax:631-854-0108
Practice Address - Street 1:1869 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4625
Practice Address - Country:US
Practice Address - Phone:631-853-3400
Practice Address - Fax:631-853-3493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5155200R261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03003707Medicaid
NY03003707Medicaid