Provider Demographics
NPI:1306350715
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 AND 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:DIABETES WELLNESS PROGRAM
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4870
Mailing Address - Country:US
Mailing Address - Phone:631-687-4188
Mailing Address - Fax:631-687-2879
Practice Address - Street 1:103 W MAIN ST
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:631-687-4188
Practice Address - Fax:631-687-2879
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-21
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5123000H174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty