Provider Demographics
NPI:1710934682
Name:TRAHAN, RUSSELL FREDERICK
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:FREDERICK
Last Name:TRAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 W 90TH ST
Mailing Address - Street 2:PH2A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-1100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:247 W 145TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10039-4004
Practice Address - Country:US
Practice Address - Phone:212-281-9300
Practice Address - Fax:212-491-7984
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003996213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY480005657OtherRAILROAD MEDICARE
NYP41091Medicare PIN
NY480005657OtherRAILROAD MEDICARE
NY0946880001Medicare NSC