Healthcare Provider Details

I. General information

NPI: 1114014065
Provider Name (Legal Business Name): BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 03/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 HOSPITAL ROAD
PATCHOGUE NY
11772
US

IV. Provider business mailing address

P.O. BOX 22027
ALBANY NY
12201-2027
US

V. Phone/Fax

Practice location:
  • Phone: 631-654-7728
  • Fax: 631-447-3698
Mailing address:
  • Phone: 631-321-8043
  • Fax: 631-321-4235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier02198121
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name: KENNETH S SCHWARTZ
Title or Position: DIRECTOR
Credential: MD
Phone: 631-654-7728