MEDICARE: MR. ROBERT R VAN TRUMP P.A.

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	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1548427081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT R VAN TRUMP P.A.

Provider Business Mailing Address
First Line	:	PO BOX 469
Second Line	:
City	:	ERIN
State	:	TN
Zip	:	37061-0469
Country	:	US
Telephone Number	:	931-289-4201
Fax Number	:	931-289-4204

Provider Business Practice Location Address
First Line	:	4891 E MAIN ST
Second Line	:
City	:	ERIN
State	:	TN
Zip	:	37061-4115
Country	:	US
Telephone Number	:	931-289-4201
Fax Number	:	931-289-4204

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

Provider Enumeration Date	:	05/21/2008
Last Update Date	:	05/21/2008

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