Basic Information
| Provider Information | |||||||||
| NPI: | 1891183950 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VALLEY STREAM MEDICAL OF NEW YORK, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4141 DUNDEE RD | ||||||||
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| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600622129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475938460 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2511 OCEAN AVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112293950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183011100 | ||||||||
| FaxNumber: | 2242468042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2014 | ||||||||
| LastUpdateDate: | 12/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | KATSNELSON | ||||||||
| AuthorizedOfficialFirstName: | YAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8472571244 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.