Healthcare Provider Details

I. General information

NPI: 1891183950
Provider Name (Legal Business Name): VALLEY STREAM MEDICAL OF NEW YORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2014
Last Update Date: 12/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 OCEAN AVE SUITE 102
BROOKLYN NY
11229-3950
US

IV. Provider business mailing address

4141 DUNDEE RD
NORTHBROOK IL
60062-2129
US

V. Phone/Fax

Practice location:
  • Phone: 718-301-1100
  • Fax: 224-246-8042
Mailing address:
  • Phone: 847-593-8460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: YAN KATSNELSON
Title or Position: OWNER
Credential: MD
Phone: 847-257-1244