Membership Application Form

Executive Officers  2009-2010: 

Roger Kim, MD,  President rkim@brookdale.edu 718-240-5668

Elana Altzman, MD, Vice President  elana@altzman.com 718-270-8136

Nitin Ron, MD,  Secretary  nitinron@gmail.com 718-974-5883

Levon Agdere, MD, Treasurer   coolendoman@yahoo.com  917-359-3510

James Gough, MD, Member-at-large  JamesWGough@aol.com  718-282-0170 

Maria Sanchez, Administrator  sanchezlopez@optonline.com 718-975-0746

Website http://www.bpsny.org  Phone:718-240-5628 Fax:718-240-6513

Name

Office Information

Address:

Personal Information

Telephone:                                         Email:

Education

College:

Medical School:

Internship:

Residency:

Fellowship:

2.

2.

2.

_____________________________________                                       ____________

Signature                                                                                                    Date

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 Maria Sanchez, Administrator, 

Brookdale Hospital and Medical Center, One Brookdale Plaza,  Brooklyn, NY 11212 

Email: sanchezlopez@optonline.com    Phone:718-240-5628    Fax:718-240-6513