Provider Demographics
NPI:1194812479
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:VICE PRESIDENT FINANCE
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 1:625 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:631-473-1320
Mailing Address - Fax:631-686-7972
Practice Address - Street 1:120 N COUNTRY RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2604
Practice Address - Country:US
Practice Address - Phone:631-473-1320
Practice Address - Fax:631-686-7972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW79761Medicare ID - Type UnspecifiedMRI MEDICARE GROUP #
NY97Z501Medicare PIN