Samuel C. Klagsbrun, M.D.
595 Madison Avenue license #090515
Suite 2000 SOO Cross River Raid
New York, NY 10022 Katonah. NY 10536
1-
BILL TO/PATIENT:
301 East 66th STreet, # 2G
New York, NY 10065
STATEMENT PERIOD:
July 1, 2011 - July 31, 2011
For professional services:
Date Description Amount
07/01/2011 Previous balance $ 400.00
Trti? loc -1 (..•:" It
07/05/2011 400.00
07/12/2011 )( C; 400.00
07/19/2011 400.00
07/28/2011 400.00
Balance due $ 2000.00
Provider Tax ID 132698221 Provider NPI 1508083437
Diagnosis: 309.24
Please remit your payment within 30 days, payable to DR. KLAGSBRUN. Most major credit cards accepted. 11you
have any questions, please call Renee Sibrizzi at ext. 2222. Thank you.
EFTA01168552