EFTA01118550.pdf

Samuel C. Klagsbrun, M.D. 595 Madison Avenue license #0905,5 Suite 2000 $00 Cross River Road New York, NY 10022 Katonah. NY 10536 BILL TO/PATIENT: STATEMENT PERIOD: July 1, 2011 - July 31, 2011 For professional services: Date Description Amount 07/01/201-1 Previous balance $ 400.00 N c>.c-1 (...:- , It 07/05/2011 1 400.00 07/12/2011 >e cm 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. If you have any questions, please call Renee Sibrizzi at ext. 2222. Thank you. EFTA01118550