MEDICARE: BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	5123600	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000086	OTHER	NY	EMPIRE BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104823996
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER, INC.

Provider Business Mailing Address
First Line	:	103 WEST MAIN STREET
Second Line	:
City	:	PATCHOGUE
State	:	NY
Zip	:	11772-3003
Country	:	US
Telephone Number	:	631-758-3600
Fax Number	:	631-758-3615

Provider Business Practice Location Address
First Line	:	103 WEST MAIN STREET
Second Line	:
City	:	PATCHOGUE
State	:	NY
Zip	:	11772-3003
Country	:	US
Telephone Number	:	631-758-3600
Fax Number	:	631-758-3615

Authorized Official
Title or Position	:	VICE PRESIDENT & CFO
Name	:	BRENDA J FARRELL
Credential	:
Telephone Number	:	631-654-7175

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	08/26/2019

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