EFTA01118550

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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 [Phone Redacted]
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