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Brooklyn Pediatric Society Membership Application Form |
Executive Officers 2008-2009: Leslie Alvarado, MD, President alvaradoleslie@yahoo.com Roger
Kim, MD, Vice President rkim@brookdale.edu Elana
Altzman, MD, Secretary
elana@altzman.com Nitin
Ron, MD, Treasurer nitinron@gmail.com Levon Agdere, MD, Member-at-large coolendoman@yahoo.com Mary Gallagher, Administrator pediatricgallagher@yahoo.com Website http://www.bpsny.org Phone:718-780-4892 Fax:718-780-1480 |
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Name |
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Office Information |
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Address: |
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Personal Information |
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Home Address |
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Telephone: Email: |
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Education |
College: |
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Medical School: |
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Training |
Internship: Residency: Fellowship: |
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| Board Certification | Board: | Date: | |
| Subspecialty: | Date: | ||
| Hospital Affiliations |
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| Society Memberships |
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| References |
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Comment:
_____________________________________ ____________ Signature Date |
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Annual membership dues are Regular $150, Retirees $75, and Fellows/Residents $50. Please submit your check with the completed application to: The Brooklyn Pediatric Society c/o Mary Gallagher, Administrator, 413 Vanderbilt Street, Brooklyn, NY 11218 Email: pediatricgallagher@yahoo.com Phone:718-780-4892 Fax:718-780-1480 |
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