Provider Demographics
NPI:1891183950
Name:VALLEY STREAM MEDICAL OF NEW YORK, LLC
Entity Type:Organization
Organization Name:VALLEY STREAM MEDICAL OF NEW YORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KATSNELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-257-1244
Mailing Address - Street 1:4141 DUNDEE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2129
Mailing Address - Country:US
Mailing Address - Phone:847-593-8460
Mailing Address - Fax:
Practice Address - Street 1:2511 OCEAN AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-3950
Practice Address - Country:US
Practice Address - Phone:718-301-1100
Practice Address - Fax:224-246-8042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-24
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty