=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023356318
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSSELL F TRAHAN D D P M P C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2013
-----------------------------------------------------
Last Update Date | 03/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 247 W 145TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10039-4004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-281-9300
-----------------------------------------------------
Fax | 212-491-7984
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 247 W 145TH ST
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10039-4004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-281-9300
-----------------------------------------------------
Fax | 212-491-7984
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RUSSELL TRAHAN
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 212-281-9300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 003996
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------