Healthcare Provider Details

I. General information

NPI: 1669864369
Provider Name (Legal Business Name): STATEN ISLAND MEDICAL OF NEW YORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2015
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 HYLAN BLVD STE C
STATEN ISLAND NY
10306
US

IV. Provider business mailing address

4141 DUNDEE RD
NORTHBROOK IL
60062-2129
US

V. Phone/Fax

Practice location:
  • Phone: 847-305-3346
  • Fax: 888-979-6720
Mailing address:
  • Phone: 847-257-1244
  • Fax: 224-246-8042

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: DIRECTOR
Credential: MD
Phone: 847-257-1244