Healthcare Provider Details

I. General information

NPI: 1114141298
Provider Name (Legal Business Name): BROOKHAVEN MEMORIAL HOSPITAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 EAST MAIN STREET
PATCHOGUE NY
11772-3145
US

IV. Provider business mailing address

101 HOSPITAL ROAD
PATCHOGUE NY
11772-4870
US

V. Phone/Fax

Practice location:
  • Phone: 631-866-2030
  • Fax: 631-687-1830
Mailing address:
  • Phone: 631-654-7100
  • Fax: 516-333-1075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier00245529
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

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