Provider Demographics
NPI:1104823996
Name:BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:103 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3003
Mailing Address - Country:US
Mailing Address - Phone:631-758-3600
Mailing Address - Fax:631-758-3615
Practice Address - Street 1:103 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3003
Practice Address - Country:US
Practice Address - Phone:631-758-3600
Practice Address - Fax:631-758-3615
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-07
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5123600251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000086OtherEMPIRE BLUE CROSS
NY00245529Medicaid
NY337108Medicare Oscar/Certification