MEDICARE: DR. RUSSELL FREDERICK TRAHAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	003996	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	480005657	OTHER	NY	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1710934682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL FREDERICK TRAHAN

Provider Business Mailing Address
First Line	:	250 W 90TH ST
Second Line	:	PH2A
City	:	NEW YORK
State	:	NY
Zip	:	10024-1100
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	247 W 145TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10039-4004
Country	:	US
Telephone Number	:	212-281-9300
Fax Number	:	212-491-7984

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	06/28/2012

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