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