Provider Demographics
NPI:1922525781
Name:MOTT HAVEN PROFESSIONAL MEDICAL OF NEW YORK LLC
Entity Type:Organization
Organization Name:MOTT HAVEN PROFESSIONAL MEDICAL OF NEW YORK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
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 1:304 WAINWRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1900
Mailing Address - Country:US
Mailing Address - Phone:847-257-1244
Mailing Address - Fax:224-246-8042
Practice Address - Street 1:384 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-3908
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:2017-08-23
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2655062086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105104Medicaid