1891183950 NPI number — VALLEY STREAM MEDICAL OF NEW YORK, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891183950 NPI number — VALLEY STREAM MEDICAL OF NEW YORK, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALLEY STREAM MEDICAL OF NEW YORK, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891183950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4141 DUNDEE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60062-2129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-593-8460
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2511 OCEAN AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11229-3950
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-301-1100
Provider Business Practice Location Address Fax Number:
224-246-8042
Provider Enumeration Date:
12/24/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KATSNELSON
Authorized Official First Name:
YAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
847-257-1244

Provider Taxonomy Codes

  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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