Basic Information
| Provider Information | |||||||||
| NPI: | 1922525781 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOTT HAVEN PROFESSIONAL MEDICAL OF NEW YORK LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 WAINWRIGHT DR | ||||||||
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| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600621900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8472571244 | ||||||||
| FaxNumber: | 2242468042 | ||||||||
| Practice Location | |||||||||
| Address1: | 384 E 149TH ST | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104553908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183011100 | ||||||||
| FaxNumber: | 2242468042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2017 | ||||||||
| LastUpdateDate: | 03/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | KATSNELSON | ||||||||
| AuthorizedOfficialFirstName: | YAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| 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 | 2086S0129X | 265506 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036105104 | 05 | IL | MEDICAID |