Healthcare Provider Details

I. General information

NPI: 1639585706
Provider Name (Legal Business Name): JOHN T. MATHER MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 07/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 N COUNTRY RD
PORT JEFFERSON NY
11777-2119
US

IV. Provider business mailing address

75 N COUNTRY RD
PORT JEFFERSON NY
11777-2119
US

V. Phone/Fax

Practice location:
  • Phone: 631-476-2768
  • Fax: 631-474-4939
Mailing address:
  • Phone: 631-476-2768
  • Fax: 631-474-4939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH WISNOSKI
Title or Position: SR. VP & CMO
Credential:
Phone: 631-473-1320