101 Hospital Road, Patchogue New York 11772
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1 101 Hospital Road, Patchogue New York All claims for both technical and professional component services provided by Brookhaven Memorial Hospital Medical Center are billed under the Hospital s employer identification number: Claims for Inpatient (I/P) and Outpatient (O/P) technical component services (except Homecare, Hospice and Outpatient; No Fault and Workers Compensation claims) are submitted with the following billing name and pay-to-address: Brookhaven Memorial Hospital Medical Center 101 Hospital Road Patchogue, New York NPI (National Provider ID): Medicare Provider ID(PTAN) Medicaid Provider ID Hospital: Hospital Dialysis: Hospital Psych Unit: S End Stage Renal Center: (Main St. Dialysis) Claims for O/P N/F Radiology component services provided to No Fault and Workers Comp. Patients are submitted by: Tritech Healthcare Management LLC 125 Newtown Road, Suite 200 Plainview, NY (516) Contact: Joe Pasquelina JoeP@tritechhcm Tritech uses the following billing name and pay-to-address: Brookhaven Memorial Hospital Medical Center PO Box 350 Plainview, New York 11803
2 Claims for Home Care services are submitted under the following billing name and pay-to address: Brookhaven Memorial Hospital Home Health Agency 103 West Main Street Patchogue, New York NPI: Medicare Provider Number: Medicaid Provider Number: Claims for Hospice services are submitted under the following billing name and pay-to address: Brookhaven Memorial Hospital Hospice 105 West Main Street Patchogue, New York NPI: Medicare Provider Number: Medicaid Provider Number: Professional Component Services Are billed under the Hospital s Tax ID# by HTM Healthcare Transitions Management, Inc. 1 John Street Babylon, NY Contact: Leslie Siegel (631) ext. 31 lsiegel@healthcaretransitions.com Claims for O/P Nutritional Services and O/P Diabetic Wellness Education are submitted with the following billing name and pay-to-address: Brookhaven Memorial Hospital Medical Center Group NPI: Care Group #: W70281 Fee Identifier: XXXX.55 Brookhaven Memorial Hospital Diabetes Wellness Education Group NPI: Care Group #: A Fee Identifier: XXXX.66
3 Claims for O/P EKG, EEG, Physician Assistants, Psychiatric, Palliative Care and Wound Care are submitted with the following billing name and pay-to-address: Radiology Brookhaven Memorial Hospital Medical Center EKG/EEG and Physician Assistants Group NPI: Care Group #: W70261 Fee Identifier: XXXX.33 (EKG) XXXX.22 (EEG) XXXX.88 (PA) Brookhaven Memorial Hospital Medical Center Psychiatric Group NPI: Care Group #: W86911 Fee Identifier: XXXX.11 Brookhaven Memorial Hospital Medical Center Palliative Care Group NPI: Care Group #: A Fee Identifier: XXXX.77 Brookhaven Memorial Hospital Medical Center Wound Care Group NPI: Fee Identifier: WKW881 Fee Identifier: XXXX.44 Claims for I/P and O/P Radiology Billing are submitted by New York Radiology Alliance (effective 1/1/13) With the following billing name and pay-to-address: Virtual Radiologic Professionals of NY PO Box 7067 Carol Stream, IL Patients can call The Corporate Name and address is: Virtual Radiologic Professionals Singletree Lane #500 Eden Prairie, MN Contacts: Jonathan Schwartz or Francine Kaley Phone (914) Fax (914)
4 TAX ID for the onsite Radiologists is TAX ID for the Teleradiologists is Pathology Pathology & Lab Consultant of LI 4567 Crossroads Park Drive Liverpool, NY This group bills for their own service. Provider # W PLCLI Evelyn Hill Claims for O/P Behavioral Healthcare services are submitted by East Meadow Management Group, Inc.: East Meadow Management Group Inc Old Country Rd. Westbury, NY Contact: Lorraine Donohue (516) lorraine@emmgbilling.com Claims are submitted with the following billing names and pay-to address: Brookhaven Memorial Hospital O/P Behavioral Health Services PO Box 491 Laurel, NY NPI: MH Center East W32922 NPI: MH Center West W32921 Account #: 8 Digits always beginning with 8 or 9
5 and Assistants that care for our patients in our Emergency Department are billed separately by Emergency Medicine (EMP) under a separate Tax ID. EMP of Suffolk County (ED & ED-PA Services) P.O. Box Cincinnati, OH TID: NPI: The following Physician Practices are billed under a separate Tax ID- All of the Family Medicine Locations are currently being billed by HTM. All credentialing for the physicians that are being billed by HTM are done by HTM. Brookhaven Physician Services, PC (d/b/a Brookhaven Family Medicine) Suite 203 Office Manager / Contact: Jody Falzone Phone (631) Fax (631) TID: GL: Imrana Ahmed, DO Troy Dickinson, DO Peter Eckberg, MD Ruth Guevara, MD Unnati Tailor, DO Mary Thomas, MD (Psych) (paid through BMH) Peter Urazov, DO (paid through BMH) Brookhaven Physician Services, PC (d/b/a Brookhaven Family Medicine-Bellport) 16 Station Road Suite 5-6 Bellport, NY Office Manager / Contact: Deborah Pardo Phone (631) Fax (631) TID: GL: Kym Carpentieri, DO Brookhaven Physician Services, PC (d/b/a Brookhaven Family Medicine #2) 285 Sills Road Building 5-6 Suite G
6 Office Manager / Contact: Sandy Flores Phone (631) Fax (631) TID: GL: Steven Shepherd, MD Noor Ul Ain Hashmi, DO Brookhaven Physician Services, PC (d/b/a Brookhaven Family Medicine #3) Suite 200 Office Manager / Contact: Betty Weed Phone (631) Fax (631) TID: GL: Anthony Donatelli, MD Danielle DeGaetano, DO Irina Tuckosh, PA The following Practices are currently being billed by the Practices themselves. All credentialing for the insurance companies for each of the physicians are done by Newport Credentialing Solutions, 16 Atlantic Avenue, Lynbrook, New York Contact: Allyson Schiff ext. 202 (fax ). Brookhaven Surgical Services, PC (d/b/a Bariatric and Wellness Program) 55 Medford Avenue Suite D Office Manager / Contact: Alicen Johnson Phone (631) Fax (631) TID: GL: Farhad Anoosh, MD James Sapala, MD Brookhaven Surgical Services, PC (d/b/a Brookhaven Breast Health Services) Suite 106
7 Office Manager / Contact: Margo Ellis Phone (631) Fax (631) TID: GL: Stanley Klausner, MD David Mangiameli, DO Melissa Fana, MD Brookhaven Surgical Services, PC (d/b/a Brookhaven Vascular Surgery) Suite 203 Office Manager / Contact: Sandy Schlegel Phone (631) Fax (631) TID: GL: George Koullias, MD Alison Jackson, PA Brookhaven Surgical Services, PC (d/b/a Brookhaven Thoracic Surgery) Suite 203 Office Manager / Contact: Sandy Schlegel Phone (631) Fax (631) TID: GL: Randolph Scott, MD Long Island Orthopedic and Spine Specialists, PC (LIOSS) Suite 215 Office Manager / Contact: Maria Panico-Barbato Phone (631) Fax (631) TID:
8 GL: David Angelillo, DO Alexios Apazidis, MD Freddie Barfield, PA Joseph Pattie, PA Anjani Sinha, MD
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