| | Physician Last Name: | Village Medical Services |
| | Physician First Name: | P.C. |
| | Physician Middle Name: | |
| | Address: | C/O Mitchell Grant Siller, M.D.
3408 Fulton Avenue
Oceanside, New York 11572 |
| | License Number: | 160541 |
| | License Type: | |
| | Year of Birth: |
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| | Effective Date: | 12/27/2001 |
| | Action Description for DOH Webpage: | Revocation of Certificate of Corporation |
| | Misconduct Description for DOH Webpage: | The corporation admitted to the charge of failing to comply with New York State Business Law Section 1503 |
| | License Limitations or Conditions for DOH Webpage: | |
| | Board Order: |
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