Healthcare Provider Details

I. General information

NPI: 1063846194
Provider Name (Legal Business Name): TMH MEDICAL HOME PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 02/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1274 E MAIN ST
RIVERHEAD NY
11901-2583
US

IV. Provider business mailing address

1272 E MAIN ST
RIVERHEAD NY
11901-2583
US

V. Phone/Fax

Practice location:
  • Phone: 631-284-3793
  • Fax: 631-729-3111
Mailing address:
  • Phone: 631-284-3793
  • Fax: 631-729-3111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number215053
License Number StateNY

VIII. Authorized Official

Name: DR. BELLAMY BROOK
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 631-284-3793