MEDICARE: FORDHAM PROFESSIONAL MEDICAL SERVICES OF NEW YORK LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician

General Provider Information

NPI Number	:	1124524970
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORDHAM PROFESSIONAL MEDICAL SERVICES OF NEW YORK LLC

Provider Business Mailing Address
First Line	:	304 WAINWRIGHT DR STE 110
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-1919
Country	:	US
Telephone Number	:	224-318-0118
Fax Number	:	224-235-4652

Provider Business Practice Location Address
First Line	:	11 E FORDHAM RD STE A
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10468-5406
Country	:	US
Telephone Number	:	847-593-8460
Fax Number	:	224-235-4652

Authorized Official
Title or Position	:	OWNER
Name	:	YAN KATSNELSON
Credential	:	M.D.
Telephone Number	:	224-318-0118

Provider Enumeration Date	:	04/02/2018
Last Update Date	:	04/02/2018

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