# JOHN T MATHER MEMORIAL HOSPITAL

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Medical Weight Management
- **Organization subpart:** No

## Provider details

- **NPI number:** 1265844716
- **Authorized official:** MR. JOSEPH WISNOSKI CFO (VP FINANCE)
- **Authorized official phone:** (631) 473-1320

## Contact information

- **Practice address:** 625 BELLE TERRE RD, SUITE 203, PORT JEFFERSON, NY 11777-2316
- **Practice address phone:** (631) 686-7897
- **Practice address fax:** (631) 686-2503
- **Mailing address:** 625 BELLE TERRE RD, SUITE 203, PORT JEFFERSON, NY 11777-2316
- **Mailing address phone:** (631) 686-7897
- **Mailing address fax:** (631) 686-2503

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 133VN1006X | Metabolic Nutrition Registered Dietitian | — | NULL | Yes |
| 133VN1006X | Metabolic Nutrition Registered Dietitian | — | — | Yes |
| 363AM0700X | Medical Physician Assistant | — | NULL | — |
| 363AM0700X | Medical Physician Assistant | — | — | — |

## Other

- **Enumeration date:** 06/02/2014
- **Last updated:** 08/27/2014