seth stabinsky, m.d.'s arizona license applications

8/11/2019 SETH STABINSKY, M.D.'S ARIZONA LICENSE APPLICATIONS

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Arizona Medical Board9545 E. Doubletree Ranch Road Scottsdale, AZ 85258-5514

Telephone: 480- 551-2700 Fax: 480-551-2704Website: www.azmd.gov

January 28, 2013

Seth Alan Stabinsky, M.D.

Dear Dr. Stabinsky:

This will acknowledge receipt of your application for licensure to practice medicine in the Stateof Arizona. I have reviewed your application. To complete the processing of your application, thefollowing documentation is still required:

1) Evidence of Name and Date of Bir th (Copy of Passport or Bir th Certi ficate)2) Medical College Transcripts3) NBME Exam Scores (available online at www.nbme.org)4) Hospital Affili ations/Medical Employment verification from:

a) Tiburcio Vasquez Health Centerb) Livingston Medical Groupc) Planned Parenthood Mar Monted) Regional Medical Center

*Note: Information will be provided by FCVS if you are using their service

All documents must come from the primary source.

Please be advised final action cannot be taken until the required information is in yourapplication file. It is your responsibility to ensure that the Board receives all documentation.

Please be advised that if your application is not fully complete within one year from this date,your application is deemed withdrawn.

Should your application be approved, you will be notified of the initial licensing fee due for

issuance of your license.

Sincerely,Arizona Medical Board


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400 Fuller Wiser Road, Suite 300, Euless, TX 76039

Tel: (817) 868-5000 Fax: (817) 868-5099

Federation Credentials Verification Service (FCVS)

Verification of Graduate Medical Education

Institution: Bronx Municipal Hospital Center

Specialty: Obstetrics and Gynecology

Address: Bronx, NY

Attention: Jacobi Medical Ctr - House Staff Office

Verification For: Name: STABINSKY, SETH ALAN

DOB:

Individual's Name on Record (If different from above):

Specialty/Subspecialty: OB/GYN & Women's Health

Successfully Completed?:



Yes

Accredited by: LCGME

From:07/01/1987 To: 06/30/1988

In ProgressNo

RSCAOAACGME

Internship

Residency

Fellowship

Research

Training Level:1(e.g., 1, 2, 3, etc.)

Training Level:(e.g., 1, 2, 3, etc.)

Internship

Residency

Fellowship

Research

From: / / To: / /

Accredited by: ACGME AOA

Yes No In Progress

From: / / To: / /

Yes No In Progress

Accredited by: ACGME AOA

Training Level:(e.g., 1, 2, 3, etc.)

Internship

Residency

Fellowship

Research

Report IncompleteTraining Levels (years)separate from those thatwere successfullycompleted.

If the training level (year) iscurrently in progress reportthe expected completiondate in the "To" field.

Report Internships,Residencies andFellowships separately.

Use one section perDepartment/Specialty. If theDepartment/Specialty isrotating or transitional, please

provide a schedule ofrotations.

Important:

Program

Participation:

CFPC

RCPSC APPAP None of these

CFPCRSC

None of theseAPPAPRCPSC

LCGME

None of theseAPPAPRCPSC

LCGME CFPCRSC

Chief Residency

Chief Residency

Chief Residency

Specialty/Subspecialty:

Specialty/Subspecialty:

Yes No1.Did this individual ever take a leave of absence or break from his/her training?

Yes No2.Was this individual ever placed on probation? .

3.Was this individual ever disciplined or placed under investigation? .

4.Were any negative reports for behavioral reasons ever filed by instructors? .....

Yes No

Yes No

Please explain any "Yes" response from above:

5.Were any limitations or special requirements placed upon this individual because

of questions of academic incompetence, disciplinary problems or any other reason?

Check the correct response.Omitted responses requirewritten explanation.

If necessary, you maycontinue your explanationon a separate sheet ofpaper.

Yes No

Unusual

Circumstances:

no seal is available,you must have this

form notarized.E-Mail: [email protected]: 718-430-4031 Fax: 718-430-2576

Affix your institutionalseal in this space. If Signature: Erika H. Bank,MD

Title of Signatory: Program Director

Name: Erika H. Banks, MD

Date of Signature: _12/13/2012______

Certification:

Rev. 12/12/2012 FCVS ID: 262206 FID: 206111874 CODE: 117220

Affiliated

University: Albert Einstein College of Medicine/MMC

Completion of the following is certification that the information above is an accurate account of this individuals records and is trueand correct. The signature line must contain the original signature, or the electronic typed signature, of the program director(M.D./D.O. onl y).

Certification:

Affix your institutionalseal in this space. Ifno seal is available,you must have this

form notarized


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seth stabinsky, m.d.'s arizona license applications

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