Brooklyn Pediatric Society

Membership Form

Executive Officers  2011-2012: 

Nitin Ron, MD, President 718-974-5883
Levon Agdere, MD, Vice-President 917-359-3510
Leslie Hayes, MD, Treasurer 718-250-6594
Danthanh Hoang, MD, Member-at Large 718- 780- 6257
Elana Altzman, MD, Past President 718-270-8136
Leslie Alvarado, MD, Past President 718-833-3636
Roger Kim, MD, Past President 718-240-5668
Mary Gallagher, Administrator 718-780-5268

Name

Office Information

Address:
Telephone: Email:
Fax: Website:

Personal Information

Home Address

Telephone:                                         Email:

Education

College:

Medical School:

Training

Internship:

Residency:

Fellowship:
Board Certification Board: Date:
Subspecialty: Date:
Hospital Affiliations 1. 

2.
Society Memberships 1.

2.
References 1.

2.

Comment:

_____________________________________                                       ____________

Signature                                                                                                    Date

Annual membership dues are Regular $150,    Retirees $75,    and   Fellows/Residents $50. 

Please submit your check with the completed application to:   Brooklyn Pediatric Society  

New York Methodist Hospital,,   Dept of Pediatrics,  506, 6th Street,    Brooklyn NY 11215