101 Hospital Road, Patchogue New York 11772 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: 11-1704595 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 11772 NPI (National Provider ID): Medicare Provider ID(PTAN) Medicaid Provider ID Hospital: 1053354100 330141 00245529 Hospital Dialysis: 1235210931 332332 02999686 Hospital Psych Unit: 1528133147 33S141 02999700 End Stage Renal Center: 1487743480 333527 02999695 (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 11803 (516) 454-0700 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
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 11772 NPI: 1104823996 Medicare Provider Number: 337108 Medicaid Provider Number: 02999668 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 11772 NPI: 1609877364 Medicare Provider Number: 331537 Medicaid Provider Number: 01143186 Professional Component Services Are billed under the Hospital s Tax ID# 11-1704595 by HTM Healthcare Transitions Management, Inc. 1 John Street Babylon, NY 11702 Contact: Leslie Siegel (631) 321-1212 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: 1639121825 Care Group #: W70281 Fee Identifier: XXXX.55 Brookhaven Memorial Hospital Diabetes Wellness Education Group NPI: 1508003716 Care Group #: A100001131 Fee Identifier: XXXX.66
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: 1487843090 Care Group #: W70261 Fee Identifier: XXXX.33 (EKG) XXXX.22 (EEG) XXXX.88 (PA) Brookhaven Memorial Hospital Medical Center Psychiatric Group NPI: 1346429115 Care Group #: W86911 Fee Identifier: XXXX.11 Brookhaven Memorial Hospital Medical Center Palliative Care Group NPI: 1417232760 Care Group #: A100061225 Fee Identifier: XXXX.77 Brookhaven Memorial Hospital Medical Center Wound Care Group NPI: 1598945735 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 60122-7067 Patients can call 800-822-7695 The Corporate Name and address is: Virtual Radiologic Professionals 11995 Singletree Lane #500 Eden Prairie, MN 55344 Contacts: Jonathan Schwartz or Francine Kaley Phone (914) 666-2220 Fax (914) 666-2430
Jonathan.Schwartz@nyradalliance.com Francine.Kaley@nyradalliance.com TAX ID for the onsite Radiologists is 204360799 TAX ID for the Teleradiologists is 412007905 Pathology Pathology & Lab Consultant of LI 4567 Crossroads Park Drive Liverpool, NY 13088 This group bills for their own service. Provider # W 70251 PLCLI 866-434-9547 Evelyn Hill Claims for O/P Behavioral Healthcare services are submitted by East Meadow Management Group, Inc.: East Meadow Management Group Inc. 1400 Old Country Rd. Westbury, NY 11590 Contact: Lorraine Donohue (516) 338-5300 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 11948 NPI: MH Center East 1902029796 W32922 NPI: MH Center West 1114141298 W32921 Account #: 8 Digits always beginning with 8 or 9
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 636827 Cincinnati, OH 45263-6827 TID: 27-2792299 NPI: 1669783924 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 687-4247 Phone (631) 475-6900 Fax (631) 447-5954 TID: 26-0628913 GL: 1099-158040 Imrana Ahmed, DO 1891097416 Troy Dickinson, DO 1619064060 Peter Eckberg, MD 1568564250 Ruth Guevara, MD 1154556199 Unnati Tailor, DO 1912920158 Mary Thomas, MD (Psych) 1710033287 (paid through BMH) Peter Urazov, DO 1003070558 (paid through BMH) Brookhaven Physician Services, PC (d/b/a Brookhaven Family Medicine-Bellport) 16 Station Road Suite 5-6 Bellport, NY 11713 Office Manager / Contact: Deborah Pardo 286-3995 Phone (631) 286-3995 Fax (631) 286-4573 TID: 26-0628913 GL: 1099-158050 Kym Carpentieri, DO 1649229055 Brookhaven Physician Services, PC (d/b/a Brookhaven Family Medicine #2) 285 Sills Road Building 5-6 Suite G
Office Manager / Contact: Sandy Flores 654-0335 Phone (631) 654-0335 Fax (631) 654-5925 TID: 26-0628913 GL: 1099-158060 Steven Shepherd, MD 1427149988 Noor Ul Ain Hashmi, DO 1619263746 Brookhaven Physician Services, PC (d/b/a Brookhaven Family Medicine #3) Suite 200 Office Manager / Contact: Betty Weed 730-8542 Phone (631) 730-8542 Fax (631) 730-6946 TID: 26-0628913 GL: 1099-158080 Anthony Donatelli, MD 1730176793 Danielle DeGaetano, DO 1629291216 Irina Tuckosh, PA 1467796334 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 11563 Contact: Allyson Schiff 516-593-1380 ext. 202 (fax 516-566-2375). Brookhaven Surgical Services, PC (d/b/a Bariatric and Wellness Program) 55 Medford Avenue Suite D Office Manager / Contact: Alicen Johnson 687-5400 Phone (631) 687-5400 Fax (631) 687-5430 TID: 26-0885844 GL: 1099-158160 Farhad Anoosh, MD 1558501668 James Sapala, MD 1720086374 Brookhaven Surgical Services, PC (d/b/a Brookhaven Breast Health Services) Suite 106
Office Manager / Contact: Margo Ellis 475-8846 Phone (631) 475-8846 Fax (631) 475-8860 TID: 26-0885844 GL: 1099-158180 Stanley Klausner, MD 1669692810 David Mangiameli, DO 1861659826 Melissa Fana, MD 1104073832 Brookhaven Surgical Services, PC (d/b/a Brookhaven Vascular Surgery) Suite 203 Office Manager / Contact: Sandy Schlegel 438-5030 Phone (631) 438-5030 Fax (631) 447-5954 TID: 26-0885844 GL: 1099-158170 George Koullias, MD 1992986509 Alison Jackson, PA 1154395788 Brookhaven Surgical Services, PC (d/b/a Brookhaven Thoracic Surgery) Suite 203 Office Manager / Contact: Sandy Schlegel 438-5030 Phone (631) 438-5030 Fax (631) 447-5954 TID: 26-0885844 GL: 1099-158175 Randolph Scott, MD 1124104138 Long Island Orthopedic and Spine Specialists, PC (LIOSS) Suite 215 Office Manager / Contact: Maria Panico-Barbato 687-2371 Phone (631) 687-4200 Fax (631) 687-4239 TID: 27-4670754
GL: 1099-158190 David Angelillo, DO 1497959464 Alexios Apazidis, MD 1245494368 Freddie Barfield, PA 1568472066 Joseph Pattie, PA 1447593009 Anjani Sinha, MD 1932233715