EFTA01168552.pdf

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