=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467861500
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRINITY MEDICAL CARE NY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2014
-----------------------------------------------------
Last Update Date | 08/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1845 ADAM CLAYTON POWELL JR BLVD
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10026-3625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-380-0487
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 HUGUENOT ST APT 218
-----------------------------------------------------
City | NEW ROCHELLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10801-6388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CANDICE FRASER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 860-380-0487
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 269597
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------