Healthcare Provider Details

I. General information

NPI: 1417232760
Provider Name (Legal Business Name): BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 06/02/2022
Certification Date: 06/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL ROAD
PATCHOGUE NY
11772-4870
US

IV. Provider business mailing address

101 HOSPITAL ROAD
PATCHOGUE NY
11772-4870
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-7739
  • Fax: 631-447-3098
Mailing address:
  • Phone: 631-654-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BRENDA J FARRELL
Title or Position: VICE PRESIDENT & CFO
Credential:
Phone: 631-654-7175