Healthcare Provider Details

I. General information

NPI: 1144665340
Provider Name (Legal Business Name): BROOKHAVEN FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL ROAD
PATCHOGUE NY
11772
US

IV. Provider business mailing address

101 HOSPITAL ROAD
PATCHOGUE NY
11772
US

V. Phone/Fax

Practice location:
  • Phone: 631-687-6900
  • Fax: 631-447-5954
Mailing address:
  • Phone: 631-447-3036
  • Fax: 631-447-3053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MRS. LINDA ELLEN MILLEISEN
Title or Position: PSYCHOTHERAPIST
Credential: LCSW-R
Phone: 631-447-3036