Healthcare Provider Details

I. General information

NPI: 1710934682
Provider Name (Legal Business Name): DR. RUSSELL FREDERICK TRAHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 W 145TH ST
NEW YORK NY
10039-4004
US

IV. Provider business mailing address

250 W 90TH ST PH2A
NEW YORK NY
10024-1100
US

V. Phone/Fax

Practice location:
  • Phone: 212-281-9300
  • Fax: 212-491-7984
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number003996
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: