Healthcare Provider Details

I. General information

NPI: 1003393299
Provider Name (Legal Business Name): BUSHWICK PROFESSIONAL MEDICAL SERVICES OF NEW YORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

441 KNICKERBOCKER AVE STE A
BROOKLYN NY
11237-4508
US

IV. Provider business mailing address

PO BOX 32
NORTHBROOK IL
60065-0032
US

V. Phone/Fax

Practice location:
  • Phone: 347-773-2684
  • Fax: 718-261-3893
Mailing address:
  • Phone: 847-593-8460
  • Fax: 224-235-4652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: YAN KATSNELSON
Title or Position: OWNER
Credential:
Phone: 224-318-0118