Healthcare Provider Details

I. General information

NPI: 1356739668
Provider Name (Legal Business Name): VALLEY STREAM PROFESSIONAL MEDICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2015
Last Update Date: 01/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 W SUNRISE HWY
VALLEY STREAM NY
11581-1011
US

IV. Provider business mailing address

4141 DUNDEE RD
NORTHBROOK IL
60062-2129
US

V. Phone/Fax

Practice location:
  • Phone: 718-310-1100
  • Fax: 224-246-8042
Mailing address:
  • Phone: 847-257-1244
  • Fax: 224-245-8042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

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